Basic Information
| Provider Information | |||||||||
| NPI: | 1043385982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TUSTIN HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NEWPORT SPECIALTY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14662 NEWPORT AVENUE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146197700 | ||||||||
| FaxNumber: | 9497324671 | ||||||||
| Practice Location | |||||||||
| Address1: | 14662 NEWPORT AVENUE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146197700 | ||||||||
| FaxNumber: | 9497324671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLOM | ||||||||
| AuthorizedOfficialFirstName: | CLARA | ||||||||
| AuthorizedOfficialMiddleName: | RUTH | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/HOSPITAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 3104638273 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | IX | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3140N1450X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | LTC40006F | 05 | CA | MEDICAID |