NPIMap

Organization Active NPI

Marshall Medical Center

Doing business as Marshall Pediatric Clinic

  • Rural Health Clinic/Center
  • Placerville, CA
National Provider Identifier
1386065480
Registry record updated Sep 29, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MARSHALL MEDICAL CENTER
Doing business as
Marshall Pediatric Clinic
Practice address
4341 Golden Center Dr
Suite a
Placerville, CA 95667-6260
Phone
(530) 626-1144
NPI assigned
Dec 17, 2013
Last updated
Sep 29, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 29, 2026

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

Authorized official

Name
Martin Entwistle
Title
Interim Ceo
Phone
(530) 626-2868

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X CA Primary
Pediatrics Physician 208000000X 030000059 CA

Addresses

Primary practice location

4341 Golden Center Dr
Suite a
Placerville, CA 95667-6260

Mailing address

PO Box 45680
San Francisco, CA 94145-0680
Phone (530) 626-2787

Other names 1

  • Marshall Pediatric Clinic Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140620001114 CA Part A Provider - Rural Health Clinic 7517875859 Practice locations: Placerville, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1386065480. Details of each certification follow.

Rural health clinic certification: CCN 058682

Legal name
MARSHALL MEDICAL CENTER
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 9, 2015
Last certification
Jun 9, 2015
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Mar 21, 1957 in CA
Enrollment address
4341 Golden Center Dr a
Placerville, CA 95667-6260
Related CCNs
050254

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Marshall Medical Center for18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

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

View all 17

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Sylvia Doane-Stephenson Individual Corporate DirectorBoard Member Jun 27, 2024
Leanne M Camisa Individual Corporate DirectorChief of Staff Jan 1, 2025
Brian Keith Veerkamp Individual Corporate DirectorBoard of Directors Mar 30, 2020
Jon Christian Haugaard Individual Corporate DirectorBoard Chair Mar 30, 2018
John Rodman Knight Individual Corporate DirectorTreasurer/Secretary of the Board Mar 30, 2020
Siri Nelson Individual Corporate OfficerCeo Jan 1, 2020
Corporate DirectorCeo Jan 1, 2020
W-2 Managing EmployeeCeo Jan 1, 2020
Kim Stoll Individual Corporate DirectorBoard of Directors Mar 31, 2023 6.66%
Anna-Nicole M Blair Individual Corporate DirectorBoard of Directors Mar 31, 2023 6.66%
Jonathan Russell Individual Corporate OfficerChief Ambulatory Officer Dec 27, 2020
Corporate DirectorChief Ambulatory Officer Dec 27, 2020
W-2 Managing EmployeeChief Ambulatory Officer Dec 27, 2020
Office of Statewide Health Planning and Development Organization, Sacramento, CA 5% Or Greater Mortgage Interest Oct 1, 1986 26%
5% Or Greater Security Interest Oct 1, 1986 26%
Michael Lewis Purvis Individual Corporate DirectorBoard Member Jan 25, 2024 6.66%
Gerardo S Galang Individual Corporate DirectorBoard of Directors Jul 1, 2022 6.66%
Thomas Cumpston Individual Corporate DirectorVice Chair Mar 30, 2019
US Bank National Association Organization, Monterey Park, CA Financial institution 5% Or Greater Mortgage Interest May 30, 2023 26%
5% Or Greater Security Interest May 30, 2023 26%
Alexis F Long Individual Corporate DirectorBoard of Directors Mar 25, 2021 6.66%
Cynthia Anne Rice Individual Corporate OfficerCno Dec 10, 2021 25%
Corporate DirectorVP of Clinical Nursing Aug 14, 2001
W-2 Managing EmployeeVP of Clinical Nursing Aug 14, 2001

Owners & managing parties with NPI records 3

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Divide Wellness CenterGeorgetown, CA, CCN 058514 Rural health clinic Operational/Managerial Control Jun 1, 2009

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1387238400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1790640000000",
    "number": "1386065480",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 45680",
            "city": "SAN FRANCISCO",
            "state": "CA",
            "postal_code": "941450680",
            "telephone_number": "530-626-2787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4341 GOLDEN CENTER DR",
            "address_2": "SUITE A",
            "city": "PLACERVILLE",
            "state": "CA",
            "postal_code": "956676260",
            "telephone_number": "530-626-1144"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARSHALL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-12-17",
        "last_updated": "2026-09-29",
        "certification_date": "2026-09-29",
        "status": "A",
        "authorized_official_last_name": "ENTWISTLE",
        "authorized_official_first_name": "MARTIN",
        "authorized_official_title_or_position": "INTERIM CEO",
        "authorized_official_telephone_number": "530-626-2868"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "CA",
            "license": null,
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "CA",
            "license": "030000059",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Marshall Pediatric Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Placerville, CA

Sources for this page

Verify at the official NPI Registry.