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	208100000X	Physical Medicine & Rehabilitation Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1427305960
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	:	714-449-4800
Fax Number	:

Provider Business Practice Location Address
First Line	:	26522 LA ALAMEDA
Second Line	:	SUITE 120
City	:	MISSION VIEJO
State	:	CA
Zip	:	92691-6330
Country	:	US
Telephone Number	:	949-364-9631
Fax Number	:

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

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	12/01/2025

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Directions to “PROVIDENCE MEDICAL FOUNDATION ” Practice Location

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