1861410581 NPI number — DIGNITY HEALTH MEDICAL FOUNDATION

Table of content: (NPI 1861410581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861410581 NPI number — DIGNITY HEALTH MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGNITY HEALTH MEDICAL FOUNDATION
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:
DIGNITY HEALTH MEDICAL GROUP - STOCKTON, A SERVICE OF DIGNITY HEALTH M
Provider Other Organization Name Type Code:
3
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:
1861410581
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-379-2840
Provider Business Mailing Address Fax Number:
916-859-1106

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3132 W MARCH LN
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95219-2354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-475-5500
Provider Business Practice Location Address Fax Number:
209-475-5515
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HYLEN
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
916-851-2559

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7291 . This is a "STOCKTON LOC - HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: GR0091671 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 371518341 . This is a "STOCKTON LOC - IRS SP TAX" identifier . This identifiers is of the category "OTHER".
  • Identifier: ZZZ66457Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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