MEDICARE: PROVIDENCE MEDICAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6852510001	OTHER	CA	NSC

General Provider Information

NPI Number	:	1386937225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE MEDICAL FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 31001 - 1920
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-1920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2826 HARRIS ST
Second Line	:
City	:	EUREKA
State	:	CA
Zip	:	95503-4809
Country	:	US
Telephone Number	:	707-443-8066
Fax Number	:	707-268-3251

Authorized Official
Title or Position	:	ASSISTANT SECRETARY OF ENROLLMENTS
Name	:	DONALD W. ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	05/25/2011
Last Update Date	:	12/03/2025

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Directions to “PROVIDENCE MEDICAL FOUNDATION ” Practice Location

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