Healthcare Provider Details

I. General information

NPI: 1770093734
Provider Name (Legal Business Name): PROVIDENCE SAINT JOHNS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404-2303
US

IV. Provider business mailing address

PO BOX 31001-3029
PASADENA CA
91110-3029
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD W. ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786