Provider Demographics
NPI:1689875601
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:15031 RINALDI STREET
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1207
Mailing Address - Country:US
Mailing Address - Phone:818-365-8051
Mailing Address - Fax:818-898-4569
Practice Address - Street 1:15031 RINALDI STREET
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1207
Practice Address - Country:US
Practice Address - Phone:818-365-8051
Practice Address - Fax:818-898-4569
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207P00000X
207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101520Medicaid
CAGR0101520Medicaid