Provider Demographics
NPI:1477587632
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:PROVIDENCE HOLY CROSS MEDICAL CENTER
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:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 31001-3017
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-3017
Mailing Address - Country:US
Mailing Address - Phone:310-303-7143
Mailing Address - Fax:310-303-7575
Practice Address - Street 1:15031 RINALDI ST
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345
Practice Address - Country:US
Practice Address - Phone:818-365-8051
Practice Address - Fax:818-496-4565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT30278GMedicaid
CAZZT40278GMedicaid
CAHSC30278GMedicaid
CAZZZD1940ZOtherBLUE SHIELD PROV#
CA050278OtherBLUE CROSS PROV#
WA050278Medicare Oscar/Certification
CA050278Medicare UPIN
CAZZT30278GMedicaid