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General NPI Number Information
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NPI Number | 1770093734
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Entity Type | Organization
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Legal Business Name | PROVIDENCE SAINT JOHNS MEDICAL FOUNDATION
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Dates
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Enumeration Date | 10/04/2017
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 2121 SANTA MONICA BLVD
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City | SANTA MONICA
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State | CA
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Zip | 90404-2303
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Country | US
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Telephone | 310-582-7312
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Fax |
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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 |
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Fax |
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | MR. 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 | 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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Taxonomy #2
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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 #3
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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 #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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