Provider Demographics
NPI:1124026273
Name:PROVIDENCE SAINT JOHN'S HEALTH CENTER
Entity Type:Organization
Organization Name:PROVIDENCE SAINT JOHN'S HEALTH CENTER
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:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:1328 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2032
Mailing Address - Country:US
Mailing Address - Phone:310-829-5511
Mailing Address - Fax:310-315-6135
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-5511
Practice Address - Fax:310-315-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000158282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT30290FMedicaid
CAZZT40290FMedicaid
CA050290Medicare Oscar/Certification
WA050290Medicare Oscar/Certification