Provider Demographics
NPI:1396725677
Name:MARIN GENERAL HOSPITAL
Entity type:Organization
Organization Name:MARIN GENERAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXEC. OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMANICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-925-7100
Mailing Address - Street 1:PO BOX 8010
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94912-8010
Mailing Address - Country:US
Mailing Address - Phone:415-925-7100
Mailing Address - Fax:415-925-7933
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-925-7100
Practice Address - Fax:415-925-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000361282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSM003606Medicaid
CAHSM003606Medicaid