Provider Demographics
NPI:1942247291
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 2335
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99210-2335
Mailing Address - Country:US
Mailing Address - Phone:310-303-7496
Mailing Address - Fax:310-303-7575
Practice Address - Street 1:1300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3505
Practice Address - Country:US
Practice Address - Phone:310-303-7496
Practice Address - Fax:310-303-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSC30078GMedicaid
CAZZT30078GMedicaid
CAZZZA1925ZOtherBLUE SHIELD PROV NUMBER
CAZZT40078GMedicaid
CA050078OtherBLUE CROSS PROV NUMBER
CAHSD30078GMedicaid
CA050078OtherBLUE CROSS PROV NUMBER
CAM050078Medicare ID - Type UnspecifiedMEDICARE PROF PROV#
WA050078Medicare Oscar/Certification
CA050078Medicare ID - Type UnspecifiedMEDICARE PROV#