NPIMap

Organization Active NPI

Providence Medical Foundation

  • Urology Physician
  • Apple Valley, CA
National Provider Identifier
1053616706
Registry record updated Dec 1, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
Legal business name
PROVIDENCE MEDICAL FOUNDATION
Practice address
19333 Bear Valley Rd
Suite 106
Apple Valley, CA 92308-5148
Phone
(760) 240-5505
Fax
(760) 245-5525
NPI assigned
Jan 11, 2011
Last updated
Dec 1, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 1, 2025

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

Authorized official

Name
Donald W. Anderson Jr.
Title
Assistant Secretary of Enrollments
Phone
(425) 358-9786

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Radiology Clinic/Center 261QR0200X
Durable Medical Equipment & Medical Supplies 332B00000X
Urology Physician 208800000X Primary

Addresses

Primary practice location

19333 Bear Valley Rd
Suite 106
Apple Valley, CA 92308-5148

Mailing address

PO Box 31001 - 1920
Pasadena, CA 91110-1920
Phone (714) 449-4800

Other names 2

  • St Joseph Heritage Healthcare Former legal business name
  • St Jude Hospital Yorba Linda Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040216001346 CA Part B Supplier - Clinic/Group Practice 8921993205 Receives reassigned benefits from 1,892 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment

Other NPIs on the same Medicare enrollment 10

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

National Provider Directory

National Provider Directory
Tax ID family
St Joseph Hospital Oran44 organizations share this tax ID, including this one

Other organizations with this tax ID 43

Organizations that report the same tax identification number in the National Provider Directory.

View all 43

Locations

1162 Montgomery Dr
Ste 200
Santa Rosa, CA 95405
Phone (707) 890-4100

500 Doyle Park Dr
Ste G05
Santa Rosa, CA 95405
Phone (707) 576-7100

Practitioners & affiliated clinicians

Practitioners 233

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.

View all 233

NPI Registry JSON

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

{
    "created_epoch": "1294704000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1764547200000",
    "number": "1053616706",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 31001 - 1920",
            "city": "PASADENA",
            "state": "CA",
            "postal_code": "911101920",
            "telephone_number": "714-449-4800",
            "fax_number": "714-449-4956"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19333 BEAR VALLEY RD",
            "address_2": "SUITE 106",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "923085148",
            "telephone_number": "760-240-5505",
            "fax_number": "760-245-5525"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-11",
        "last_updated": "2025-12-01",
        "certification_date": "2025-12-01",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W.",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY OF ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "",
            "desc": "Urology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Joseph Heritage Healthcare",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "St Jude Hospital Yorba Linda",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Apple Valley, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.