MEDICARE: DIGNITY HEALTH MEDICAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	0019838	OTHER	CIGNA
2	KYZ	OTHER	BLUE CROSS
3	341996544	OTHER	SPECIAL PURPOSE TAX ID #
4	ZZZ09972Z	OTHER	BLUE SHIELD
5	983	OTHER	HEALTH NET
6	195	OTHER	HEALTH NET
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558495937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGNITY HEALTH MEDICAL FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 60000
Second Line	:	FILE #72938
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94160-2938
Country	:	US
Telephone Number	:	916-733-3397
Fax Number	:

Provider Business Practice Location Address
First Line	:	7911 LAGUNA BLVD
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7920
Country	:	US
Telephone Number	:	916-733-5801
Fax Number	:	916-683-0232

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	THERESA M HYLEN
Credential	:
Telephone Number	:	916-851-2559

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	11/18/2020

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1851406540 — JAMES T LIN M.D.
Practice Location Address:

8021 LAGUNA BLVD , SUITE 3
ELK GROVE, CA
95758-7920

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1154492239 — PAUL W. JOHNSON,PH.D., D.M.D., INC.
Practice Location Address:

8007 LAGUNA BLVD , SUITE 1
ELK GROVE, CA
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1992864011 — THADDOUS L ARCHIE DDS
Practice Location Address:

8013 LAGUNA BLVD STE 2
ELK GROVE, CA
95758-7920

Practice Phone: 916-691-6020
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1982753844 — DR. WALLACE JEROME BELLAMY D.M.D.
Practice Location Address:

8007 LAGUNA BLVD , SUITE #3
ELK GROVE, CA
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1134243470 — GEORGE SHANNON MAYWEATHER D.D.S.
Practice Location Address:

8013 LAGUNA BLVD STE 1
ELK GROVE, CA
95758-7920

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1649447624 — DR. TINSUE TERRANCE FU DDS
Practice Location Address:

8007 LAGUNA BLVD , SUITE 2
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95758-7920

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Directions to “DIGNITY HEALTH MEDICAL FOUNDATION ” Practice Location

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