NPIMap

Organization Active NPI

Providence Medical Foundation

  • Family Medicine Physician
  • Brea, CA
National Provider Identifier
1871607762
Registry record updated Feb 3, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
PROVIDENCE MEDICAL FOUNDATION
Practice address
955 W Imperial Hwy Ste 110
Brea, CA 92821-3814
Phone
(714) 449-4900
NPI assigned
Aug 18, 2006
Last updated
Feb 3, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2026

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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Radiology Clinic/Center 261QR0200X NU
Oxygen Equipment & Supplies (DME) 332BX2000X 091052001 CA
Family Medicine Physician 207Q00000X NU Primary
Obstetrics & Gynecology Physician 207V00000X NU

Addresses

Primary practice location

955 W Imperial Hwy Ste 110
Brea, CA 92821-3814

Mailing address

PO Box 31001 - 1920
Pasadena, CA 91110-1920
Phone (714) 449-4841

Other practice location 1

805 W La Veta Ave Ste 101
Orange, CA 92868-3928
Phone (714) 997-9595

Other practice location 2

845 W La Veta Ave Ste 108
Orange, CA 92868-3930
Phone (714) 693-2600

Other practice location 3

478 S Anaheim Hills Rd
Anaheim, CA 92807-4241
Phone (714) 282-5437

Other practice location 4

1140 W La Veta Ave Ste 770
Orange, CA 92868-4229
Phone (714) 543-5555

Other practice location 5

1100 Trancas St Ste 209
Napa, CA 94558-2909
Phone (707) 251-1850

Other practice location 6

1140 W La Veta Ave Ste 430
Orange, CA 92868-4226
Phone (714) 543-5555

Other practice location 7

2501 E Chapman Ave
Orange, CA 92869-3204
Phone (714) 628-3230

Other practice location 8

1095 Irvine Blvd
Tustin, CA 92780-3526
Phone (714) 505-7110

Other identifiers 12

IdentifierTypeStateIssuer
GR0062052MedicaidCA
LAB76828FMedicaidCA
GR0062056MedicaidCA
GR0062050MedicaidCA
GR0062053MedicaidCA
GR0062058MedicaidCA
GR0062059MedicaidCA
GR0062051MedicaidCA
GR0062054MedicaidCA
GR0062055MedicaidCA
GR006205AMedicaidCA
GR0062057MedicaidCA

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

Other NPIs with the same Medicare PAC ID 1

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

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

Locations

955 W Imperial Hwy
Ste 110
Brea, CA 92821
Phone (714) 449-6900

253 S Diamond Bar Blvd
Diamond Bar, CA 91765
Phone (909) 860-1144

2710 Dolbeer St
Eureka, CA 95501
Phone (707) 267-2060

2773 Harris St
Ste D
Eureka, CA 95503
Phone (707) 267-2070

27231 La Paz Rd
Ste A
Laguna Niguel, CA 92677
Phone (949) 643-9111

26800 Crown Valley Pkwy
Ste 250
Mission Viejo, CA 92691
Phone (949) 364-0644

26800 Crown Valley Pkwy
Ste 320
Mission Viejo, CA 92691
Phone (949) 276-8900

26800 Crown Valley Pkwy
Ste 525
Mission Viejo, CA 92691
Phone (949) 364-1040

27799 Medical Center Rd
Ste 460
Mission Viejo, CA 92691
Phone (949) 347-0600

500 Superior Ave
Ste 160
Newport Beach, CA 92663
Phone (949) 631-8300

1140 W La Veta Ave
Ste 430
Orange, CA 92868
Phone (714) 543-5555

2501 E Chapman Ave
Orange, CA 92869
Phone (714) 628-3300

500 S Main St
Ste 1000
Orange, CA 92868

845 W La Veta Ave
Ste 101
Orange, CA 92868
Phone (714) 288-9700

141 Lynch Creek Way
Ste C
Petaluma, CA 94954
Phone (707) 763-0802

500 Doyle Park Dr
Ste 106A
Santa Rosa, CA 95405
Phone (707) 967-5721

4300 Rose Dr
Yorba Linda, CA 92886
Phone (714) 528-4211

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)…

Practitioners & affiliated clinicians

Practitioners 2,073

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 2,073

NPI Registry JSON

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

{
    "created_epoch": "1155859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1770076800000",
    "number": "1871607762",
    "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": "714-449-4841"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "955 W IMPERIAL HWY STE 110",
            "city": "BREA",
            "state": "CA",
            "postal_code": "928213814",
            "telephone_number": "714-449-4900"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "805 W La Veta Ave Ste 101",
            "address_purpose": "LOCATION",
            "city": "Orange",
            "state": "CA",
            "postal_code": "928683928",
            "country_code": "US",
            "telephone_number": "714-997-9595",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "845 W La Veta Ave Ste 108",
            "address_purpose": "LOCATION",
            "city": "Orange",
            "state": "CA",
            "postal_code": "928683930",
            "country_code": "US",
            "telephone_number": "714-693-2600",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "478 S Anaheim Hills Rd",
            "address_purpose": "LOCATION",
            "city": "Anaheim",
            "state": "CA",
            "postal_code": "928074241",
            "country_code": "US",
            "telephone_number": "714-282-5437",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1140 W La Veta Ave Ste 770",
            "address_purpose": "LOCATION",
            "city": "Orange",
            "state": "CA",
            "postal_code": "928684229",
            "country_code": "US",
            "telephone_number": "714-543-5555",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1100 Trancas St Ste 209",
            "address_purpose": "LOCATION",
            "city": "Napa",
            "state": "CA",
            "postal_code": "945582909",
            "country_code": "US",
            "telephone_number": "707-251-1850",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1140 W La Veta Ave Ste 430",
            "address_purpose": "LOCATION",
            "city": "Orange",
            "state": "CA",
            "postal_code": "928684226",
            "country_code": "US",
            "telephone_number": "714-543-5555",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2501 E Chapman Ave",
            "address_purpose": "LOCATION",
            "city": "Orange",
            "state": "CA",
            "postal_code": "928693204",
            "country_code": "US",
            "telephone_number": "714-628-3230",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1095 Irvine Blvd",
            "address_purpose": "LOCATION",
            "city": "Tustin",
            "state": "CA",
            "postal_code": "927803526",
            "country_code": "US",
            "telephone_number": "714-505-7110",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PROVIDENCE MEDICAL FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-18",
        "last_updated": "2026-02-03",
        "certification_date": "2026-02-03",
        "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": "261QR0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "332BX2000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies, Oxygen Equipment & Supplies",
            "state": "CA",
            "license": "091052001",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062052",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "LAB76828F",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062056",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062050",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062053",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062058",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062059",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062051",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062054",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062055",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR006205A",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GR0062057",
            "state": "CA"
        }
    ],
    "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 Brea, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2026; 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.