NPIMap

Organization Active NPI

Providence Medical Foundation

  • Internal Medicine Physician
  • Santa Rosa, CA
National Provider Identifier
1740584473
Registry record updated Dec 3, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
PROVIDENCE MEDICAL FOUNDATION
Practice address
500 Doyle Park Dr
Suite 303
Santa Rosa, CA 95405-4558
Phone
(707) 303-8300
Fax
(707) 303-8301
NPI assigned
Jan 10, 2011
Last updated
Dec 3, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 3, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X Primary

Addresses

Primary practice location

500 Doyle Park Dr
Suite 303
Santa Rosa, CA 95405-4558

Mailing address

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

Other practice location 1

500 Doyle Park Dr
Santa Rosa, CA 95405-4558
Phone (707) 528-1050

Other practice location 2

500 Doyle Park Dr
Santa Rosa, CA 95405-4558
Phone (707) 528-1050

Other names 1

  • St Joseph Heritage Healthcare 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.

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
05D0676808Providence Medical Foundation500 Doyle Park Dr, Ste 100, Santa Rosa, CA 95405Certificate of waiverJan 30, 2028
05D2084021Providence Medical Foundation500 Doyle Park Dr Ste 200, Santa Rosa, CA 95405Provider-performed microscopyOct 4, 2026
05D2221461Providence Medical Foundation500 Doyle Park Dr, Ste 303, Santa Rosa, CA 95405Certificate of waiverJul 17, 2027

National Provider Directory

National Provider Directory

Locations

2332 23rd St
Eureka, CA 95501
Phone (707) 444-2819

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

500 Doyle Park Dr
Ste 200
Santa Rosa, CA 95405
Phone (707) 303-1719

510 Doyle Park Dr
Santa Rosa, CA 95405
Phone (707) 303-8360

Practitioners & affiliated clinicians

Practitioners 195

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 195

NPI Registry JSON

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

{
    "created_epoch": "1294617600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1764720000000",
    "number": "1740584473",
    "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": "500 DOYLE PARK DR",
            "address_2": "SUITE 303",
            "city": "SANTA ROSA",
            "state": "CA",
            "postal_code": "954054558",
            "telephone_number": "707-303-8300",
            "fax_number": "707-303-8301"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "500 Doyle Park Dr",
            "address_purpose": "LOCATION",
            "city": "Santa Rosa",
            "state": "CA",
            "postal_code": "954054558",
            "country_code": "US",
            "telephone_number": "707-528-1050",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "500 Doyle Park Dr",
            "address_purpose": "LOCATION",
            "city": "Santa Rosa",
            "state": "CA",
            "postal_code": "954054558",
            "country_code": "US",
            "telephone_number": "707-528-1050",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-01-10",
        "last_updated": "2025-12-03",
        "certification_date": "2025-12-03",
        "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": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Joseph Heritage Healthcare",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Santa Rosa, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.