Healthcare Provider Details

I. General information

NPI: 1134880818
Provider Name (Legal Business Name): BLUE SHIELD PROMISE HEALTH PLAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38440 5TH STREET WEST
PALMDALE CA
93551
US

IV. Provider business mailing address

38440 5TH STREET WEST
PALMDALE CA
93551
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-2725
  • Fax: 661-273-2139
Mailing address:
  • Phone: 661-575-2725
  • Fax: 661-273-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN CERF
Title or Position: PRESIDENT & CEO BLUE SHIELD CA PROM
Credential:
Phone: 510-607-4376