Provider Demographics
NPI:1629291745
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:ST. MARY'S DEPARTMENT OF MEDICINE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BRETTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-750-5726
Mailing Address - Street 1:2235 HAYES ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1012
Mailing Address - Country:US
Mailing Address - Phone:415-750-5500
Mailing Address - Fax:415-750-5619
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1079
Practice Address - Country:US
Practice Address - Phone:415-668-1000
Practice Address - Fax:415-750-5899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-10
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000071261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ05047ZOtherBLUE SHIELD OF CA
CAGR0050760Medicaid
721561126OtherIRS - SP TAX ID
CAZZZ07805ZMedicare PIN
ZZZ05047ZOtherBLUE SHIELD OF CA