Healthcare Provider Details

I. General information

NPI: 1518438712
Provider Name (Legal Business Name): PROVIDENCE SAINT JOHNS MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 SANTA MONICA BLVD STE 300
SANTA MONICA CA
90404-2013
US

IV. Provider business mailing address

2020 SANTA MONICA BLVD STE 300
SANTA MONICA CA
90404-2013
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY FOR ENROLLMENT
Credential:
Phone: 425-525-5392