Provider Demographics
NPI:1144415589
Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Other - Org Name:PROVIDENCE REDWOOD MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
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 1:3300 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3120
Mailing Address - Country:US
Mailing Address - Phone:707-725-3361
Mailing Address - Fax:707-725-7212
Practice Address - Street 1:3300 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540
Practice Address - Country:US
Practice Address - Phone:707-725-3361
Practice Address - Fax:707-725-7212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-10
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000173282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043292303Medicaid
CA05Z318Medicare Oscar/Certification