Provider Demographics
NPI:1194840421
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:ST. MARY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-491-9929
Mailing Address - Street 1:3215 PROSPECT PARK DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-6017
Mailing Address - Country:US
Mailing Address - Phone:916-861-1102
Mailing Address - Fax:916-861-7707
Practice Address - Street 1:1050 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3321
Practice Address - Country:US
Practice Address - Phone:562-491-9929
Practice Address - Fax:562-491-9085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-19
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
CA930000012273R00000X, 273Y00000X, 282N00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No273R00000XHospital UnitsPsychiatric Unit
No273Y00000XHospital UnitsRehabilitation Unit
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA870692255OtherIRS
CALTC70135GMedicaid
CAZZT30191HMedicaid
CA0022013OtherAETNA
CAHSC30191HMedicaid
CAZZZA0191ZOtherBLUE SHIELD
CA050191B000000OtherCMS SECTION 1011
CAHSM30191HMedicaid
CASTMMOtherUNIVERSAL
CA870692255908130000OtherWPS TRICARE
CAZZT40191HMedicaid
CASTMMOtherUNIVERSAL
CA870692255OtherIRS
CAZZT30191HMedicaid
CALTC70135GMedicaid
CA555210Medicare Oscar/Certification