Basic Information
| Provider Information | |||||||||
| NPI: | 1710109186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE ST. MARY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 18300 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923072206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
| FaxNumber: | 7609468824 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923072206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
| FaxNumber: | 7609468824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASTILLO | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE | ||||||||
| AuthorizedOfficialTelephone: | 7609468195 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST JOSEPH HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 240000207 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT40300F | 05 | CA | MEDICAID | ZZT30300F | 05 | CA | MEDICAID |