NPIMap

Organization Active NPI

St. Joseph Health Northern California, LLC

  • General Acute Care Hospital
  • Rohnert Park, CA
National Provider Identifier
1598891905
Registry record updated Aug 15, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
140000648 Issued in CA
Legal business name
ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Practice address
1450 Medical Center Drive
Suite 3
Rohnert Park, CA 94928
Phone
(707) 547-4652
NPI assigned
Feb 27, 2007
Organization subpart
Yes
Parent organization
ST JOSEPH HEALTH SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 15, 2018

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

Authorized official

Name
Donald Wayne Anderson Jr.
Title
Director-Reimbursement Administrati
Phone
(425) 525-5392

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 140000648 CA Primary

Addresses

Primary practice location

1450 Medical Center Drive
Suite 3
Rohnert Park, CA 94928

Mailing address

1450 Medical Center Drive
Suite 3
Rohnert Park, CA 94928-2933
Phone (707) 547-4652

Other identifiers 3

IdentifierTypeStateIssuer
CMM70966FMedicaidCA
110000497OtherCALICENSE
050174OtherCAMEDICARE PROVIDER NUMBER

Other names 2

  • Santa Rosa Memorial Hospital Doing business as
  • St. Joseph Mobile Health Clinic Other name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180402002216 CA Part A Provider - Hospital 8921374562 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Santa Rosa, CA

Hospital certification: CCN 05T174

Legal name
ST JOSEPH HEALTH NORTHERN CALIFORNIA LLC
Doing business as
PROVIDENCE SANTA ROSA MEMORIAL HOSPITAL
Organization structure
LLCNon-profit
Incorporated
Oct 27, 2016 in CA
Enrollment address
1165 Montgomery Dr
Santa Rosa, CA 95405-4801
Hospital Rehabilitation Unit
Hospital subgroups
General, Acute care, Rehabilitation unit

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

Other NPIs on the same Medicare enrollment 1

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

Care Compare: Inpatient rehabilitation facility

Medicare Care Compare
Listed as
Santa Rosa Memorial HospitalCCN 05T174
Ownership
Non-profit
Certified
Feb 1, 2000

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0944345St. Joseph Mobile Health Clinic1450 Medical Center Dr, Ste 1, Rohnert Park, CA 94928Certificate of waiverApr 9, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 18

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

NameRoleSinceShare
James C Devore Individual Corporate DirectorBoard Member Jan 1, 2018
Oluyemi Adeyanju Individual Corporate OfficerSecretary Apr 1, 2018
Judith L Coffey Individual Corporate DirectorBoard Member May 26, 2021
Mary Bernadette McNulty Individual Corporate DirectorBoard Member Apr 1, 2018
Providence Health & Services - Washington Organization, Renton, WA Corporation, Non-profit Operational/Managerial Control Apr 1, 2018
John Aryanpur Individual Corporate DirectorBoard Member Jan 1, 2020
Shelby D Arveson Individual Corporate OfficerCfo May 30, 2024
Conrad Hewitt Individual Corporate DirectorBoard Member Apr 1, 2018
Donald Wayne Anderson Individual Corporate OfficerAssistant Secretary of Enrollments Apr 1, 2018
Keith Flamer Individual Corporate DirectorMember, Board of Managers Nov 28, 2023
Gregory David Hoffman Individual Corporate OfficerPresident/Ceo & Treasurer Oct 1, 2020
Jed Weissberg Individual Corporate DirectorBoard Member May 26, 2021
St. Joseph Health System Organization, Irvine, CA Corporation, Non-profit Other Apr 1, 2018
Laureen T Driscoll Individual Corporate OfficerChief Executive Jan 25, 2022
Erika K Wright Individual W-2 Managing EmployeeDelegated Official Feb 1, 2021
Pamela a Kindig Individual Corporate DirectorBoard Member Jan 1, 2020
St Joseph Health Northern California LLC Organization, Irvine, CA LLC, Non-profit 5% Or Greater Direct Ownership Interest Apr 1, 2018 100%
Providence St. Joseph Health Organization, Renton, WA Corporation, Non-profit Other Apr 1, 2018

Owners & managing parties with NPI records 11

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

Practitioners & affiliated clinicians

Affiliated clinicians 7

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

NPI Registry JSON

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

{
    "created_epoch": "1172534400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1534291200000",
    "number": "1598891905",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1450 MEDICAL CENTER DRIVE",
            "address_2": "SUITE 3",
            "city": "ROHNERT PARK",
            "state": "CA",
            "postal_code": "949282933",
            "telephone_number": "707-547-4652"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1450 MEDICAL CENTER DRIVE",
            "address_2": "SUITE 3",
            "city": "ROHNERT PARK",
            "state": "CA",
            "postal_code": "94928",
            "telephone_number": "707-547-4652"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST JOSEPH HEALTH SYSTEM",
        "enumeration_date": "2007-02-27",
        "last_updated": "2018-08-15",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "DIRECTOR-REIMBURSEMENT ADMINISTRATI",
        "authorized_official_telephone_number": "425-525-5392",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "CA",
            "license": "140000648",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CMM70966F",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "110000497",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PROVIDER NUMBER",
            "identifier": "050174",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Santa Rosa Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Santa Rosa Memorial Hospital",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Joseph Mobile Health Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Rohnert Park, CA

Sources for this page

Verify at the official NPI Registry.