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General NPI Number Information
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NPI Number | 1740584473
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Entity Type | Organization
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Legal Business Name | PROVIDENCE MEDICAL FOUNDATION
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 500 DOYLE PARK DR SUITE 303
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City | SANTA ROSA
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State | CA
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Zip | 95405-4558
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Country | US
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Telephone | 707-303-8300
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Fax | 707-303-8301
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Provider Business Mailing Address
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Address Line | PO BOX 31001 - 1920
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City | PASADENA
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State | CA
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Zip | 91110-1920
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Country | US
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Telephone | 714-449-4800
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Fax | 714-449-4956
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | DONALD W. ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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