Provider Demographics
NPI:1508998394
Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Other - Org Name:PROVIDENCE ST. JOSEPH 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:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:2700 DOLBEER ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4736
Mailing Address - Country:US
Mailing Address - Phone:707-445-8121
Mailing Address - Fax:707-269-3897
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-445-8121
Practice Address - Fax:707-269-3897
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-09
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000075273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR00006FMedicaid
CA1508998394Medicaid