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General NPI Number Information
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NPI Number | 1760425862
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Entity Type | Organization
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Legal Business Name | PROVIDENCE MEDICAL INSTITUTE
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 05/12/2025
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Provider Practice Location Address
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Address Line | 4101 TORRANCE BLVD
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City | TORRANCE
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State | CA
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Zip | 90503-4607
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Country | US
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Telephone | 310-793-8075
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Fax | 310-793-8195
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Provider Business Mailing Address
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Address Line | PO BOX 31001-3029
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City | PASADENA
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State | CA
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Zip | 91110-3029
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Country | US
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Telephone | 310-792-4015
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Fax | 310-792-4093
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | DONALD WAYNE 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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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Taxonomy #6
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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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Taxonomy #7
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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