1750309837 NPI number — PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA

Table of content: (NPI 1750309837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750309837 NPI number — PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750309837
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-3017
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-3017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11600 INDIAN HILLS RD
Provider Second Line Business Practice Location Address:
BUILDING A
Provider Business Practice Location Address City Name:
MISSION HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91345-1225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-365-8051
Provider Business Practice Location Address Fax Number:
818-496-4569
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
ASSISTANT SECRETARY ENROLLMENTS
Authorized Official Telephone Number:
425-358-9786

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LTC70041G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZT18872G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZA1901Z . This is a "BLUE SHIELD PROV#" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 555074 . This is a "BLUE CROSS PROV#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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