Provider Demographics
NPI:1710109186
Name:ST. MARY MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. MARY MEDICAL CENTER
Other - Org Name:PROVIDENCE ST. MARY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-946-8195
Mailing Address - Street 1:18300 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2206
Mailing Address - Country:US
Mailing Address - Phone:760-242-2311
Mailing Address - Fax:760-946-8824
Practice Address - Street 1:18300 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2206
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:760-946-8824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000207282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40300FMedicaid
CAZZT30300FMedicaid
CA050300Medicare Oscar/Certification