Provider Demographics
NPI:1821028200
Name:DIGNITY HEALTH MEDICAL FOUNDATION
Entity type:Organization
Organization Name:DIGNITY HEALTH MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:916-733-3401
Practice Address - Street 1:2110 PROFESSIONAL DR
Practice Address - Street 2:SUITE 190
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3752
Practice Address - Country:US
Practice Address - Phone:916-787-0404
Practice Address - Fax:916-787-0434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-03
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ25297ZOtherBLUE SHIELD
CAGR001137JOtherMEDI-CAL
CAGR001137JOtherMEDI-CAL
CAZZZ25297ZMedicare PIN
CAZZZ25297ZOtherBLUE SHIELD