NPIMap

Organization Active NPI

St. Mary Medical Center

Doing business as Providence St. Mary Medical Center

  • Advanced Practice Midwife
  • Apple Valley, CA
National Provider Identifier
1043406440
Registry record updated Dec 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Advanced Practice MidwifeTaxonomy code 367A00000X
License
NMW1225 Issued in CA
Legal business name
ST. MARY MEDICAL CENTER
Doing business as
Providence St. Mary Medical Center
Practice address
18077 US Highway 18
Apple Valley, CA 92307-2150
Phone
(760) 946-8169
Fax
(760) 946-8875
NPI assigned
Sep 19, 2007
Last updated
Dec 16, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Randall Castillo
Title
Chief Executive
Phone
(760) 946-8195

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Advanced Practice Midwife 367A00000X NMW1225 CA Primary

Addresses

Primary practice location

18077 US Highway 18
Apple Valley, CA 92307-2150

Mailing address

18300 US Highway 18
Apple Valley, CA 92307-2206
Phone (760) 242-2311

Other identifiers 1

IdentifierTypeStateIssuer
GNMW00060OtherCAMEDICAL

Other names 1

  • Providence St. Mary Medical Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20091230000214 CA Part A Provider - Hospital 6002956893 2 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Apple Valley, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043406440. Details of each certification follow.

Hospital certification: CCN 050300

Legal name
ST MARY MEDICAL CENTER
Doing business as
PROVIDENCE ST. MARY MEDICAL CENTER
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Mar 4, 2021
Beds
212
Ownership / control type
Private (not for profit)
Organization structure
CorporationNon-profit
Incorporated
Dec 30, 1953 in CA
Enrollment address
18300 US Highway 18
Apple Valley, CA 92307-2206
Main/Primary Hospital Location
Hospital subgroups
General, Acute care

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Providence St Mary Medical CenterCCN 050300 · All quality measures
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

National Provider Directory

National Provider Directory

Locations

18077 US Highway 18
Apple Valley, CA 92307
Phone (760) 242-8000

Ownership & related parties

All disclosed owners & managing parties 21

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Adolph Collaso Individual Corporate DirectorBoard Member Aug 1, 2017
Viola Paulette Deters Individual Corporate DirectorBoard Member Jan 1, 2018
Zoheir R El-Hajjaoui Individual Corporate DirectorBoard Member Jan 1, 2014
Providence Health & Services - Washington Organization, Renton, WA Corporation, Non-profit Operational/Managerial Control Dec 1, 2020
John Paul Gostanian Individual Corporate DirectorBoard Member Jan 1, 2016
Clarence Burke Individual Corporate DirectorBoard Member Jan 1, 2019
Joshua Conely Individual Corporate DirectorBoard Member Feb 1, 2025
Derek G King Individual Corporate DirectorBoard Member Jan 1, 2022
James Martin Individual Corporate OfficerAuthorized Official Jan 13, 2023
Judith Dugan Individual Corporate DirectorBoard Member Jan 1, 2018
St Mary Medical Center Organization, Apple Valley, CA Corporation, Non-profit 5% Or Greater Direct Ownership Interest Dec 1, 2020 100%
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary for Enrollment Dec 1, 2020
Eileen Haubl Individual Corporate OfficerFinancial Executive Jun 16, 2025
Gregory David Hoffman Individual Corporate OfficerPresident/Ceo & Treasurer Oct 1, 2020
Jason W Lamoreaux Individual Corporate DirectorBoard Member Jan 1, 2022
Prashanth V Kumar Individual Corporate DirectorBoard Member Jan 1, 2024
St. Joseph Health System Organization, Irvine, CA Corporation, Non-profit Other Nov 3, 2009
Jovy Lynn V Yankaskas Individual Corporate DirectorBoard Member Jan 1, 2022
Randall Tuanqui Castillo Individual Corporate OfficerCeo Aug 5, 2019
W-2 Managing EmployeeChief Executive Aug 5, 2019
Margaret M Curran Individual Corporate DirectorBoard Member Jan 1, 2024
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Other Jul 1, 2016

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 276

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 276

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1190160000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608076800000",
    "number": "1043406440",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18300 US HIGHWAY 18",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "923072206",
            "telephone_number": "760-242-2311"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18077 US HIGHWAY 18",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "923072150",
            "telephone_number": "760-946-8169",
            "fax_number": "760-946-8875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-09-19",
        "last_updated": "2020-12-16",
        "certification_date": "2020-12-16",
        "status": "A",
        "authorized_official_last_name": "CASTILLO",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE",
        "authorized_official_telephone_number": "760-946-8195"
    },
    "taxonomies": [
        {
            "code": "367A00000X",
            "taxonomy_group": "",
            "desc": "Advanced Practice Midwife",
            "state": "CA",
            "license": "NMW1225",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL",
            "identifier": "GNMW00060",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence St. Mary Medical Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Apple Valley, CA

Sources for this page

Verify at the official NPI Registry.