Provider Demographics
NPI:1922231422
Name:DIGNITY HEALTH MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:DIGNITY HEALTH MEDICAL FOUNDATION
Other - Org Name:DIGNITY HEALTH MEDICAL GROUP - STOCKTON, A SERVICE OF DIGNITY HEALTH M
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HYLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-851-2559
Mailing Address - Street 1:3000 Q ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7058
Mailing Address - Country:US
Mailing Address - Phone:916-733-5701
Mailing Address - Fax:916-859-1671
Practice Address - Street 1:1901 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6005
Practice Address - Country:US
Practice Address - Phone:209-464-0150
Practice Address - Fax:209-464-7241
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-31
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
371518341OtherIRS - SPECIAL PURPOSE TIN