NPIMap

Organization Active NPI

St. Mary Medical Center

Doing business as Providence St. Mary Medical Center

  • General Acute Care Hospital
  • Apple Valley, CA
National Provider Identifier
1669456299
Registry record updated May 9, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Acute Care HospitalTaxonomy code 282N00000X
License
240000207 Issued in CA
Legal business name
ST. MARY MEDICAL CENTER
Doing business as
Providence St. Mary Medical Center
Practice address
18300 Highway 18
Apple Valley, CA 92307
Phone
(760) 242-2311
Fax
(760) 946-8824
NPI assigned
Dec 6, 2005
Last updated
May 9, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
ST. JOSEPH HEALTH SYSTEMAs reported in NPPES

NPPES NPI Registry

Updated by the provider on May 9, 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 Enrollments
Phone
(425) 358-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 240000207 CA Primary

Addresses

Primary practice location

18300 Highway 18
Apple Valley, CA 92307

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
ZZT40300FMedicaidCA
ZZT30300FMedicaidCA

Other names 2

  • Providence St. Mary Medical Center Doing business as
  • St. Mary Regional Medical Center Former legal business name

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
Practice locations: Apple Valley, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669456299. 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
Tax ID family
St Mary Regional Med CT2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

Locations

11424 Chamberlaine Way
Ste 8
Adelanto, CA 92301
Phone (760) 246-6670

11965 Cactus Rd
Ste J
Adelanto, CA 92301
Phone (760) 246-6670

16051 Kasota Rd
Ste 800
Apple Valley, CA 92307
Phone (760) 242-3666

16077 Kamana Rd
#A
Apple Valley, CA 92307
Phone (760) 242-2111

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 2

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

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 139

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 139

Practitioners & affiliated clinicians

Practitioners 314

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 314

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": "1133827200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1746748800000",
    "number": "1669456299",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18300 HIGHWAY 18",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "92307",
            "telephone_number": "760-242-2311",
            "fax_number": "760-946-8824"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18300 HIGHWAY 18",
            "city": "APPLE VALLEY",
            "state": "CA",
            "postal_code": "92307",
            "telephone_number": "760-242-2311",
            "fax_number": "760-946-8824"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY MEDICAL CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST. JOSEPH HEALTH SYSTEM",
        "enumeration_date": "2005-12-06",
        "last_updated": "2025-05-09",
        "certification_date": "2025-05-09",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY ENROLLMENTS",
        "authorized_official_telephone_number": "425-358-9786",
        "authorized_official_name_suffix": "Jr."
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "CA",
            "license": "240000207",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZT40300F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "ZZT30300F",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Providence St. Mary Medical Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "St. Mary Regional Medical Center",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "St. Mary Regional Medical Center",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Apple Valley, CA

Sources for this page

Verify at the official NPI Registry.