Provider Demographics
NPI:1154349371
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY - ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 2335
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2335
Mailing Address - Country:US
Mailing Address - Phone:310-303-7496
Mailing Address - Fax:310-303-7496
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-832-3311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-17
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSM30078GMedicaid
CA05S078OtherBLUE CROSS
CAHSM30078GMedicaid
CA05S078Medicare Oscar/Certification