Basic Information
| Provider Information | |||||||||
| NPI: | 1083152748 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADY CHILDRENS HOSPITAL-SAN DIEGO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BEHAVIORAL HEALTH URGENT CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDREN'S WAY-MC 6029 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665484 | ||||||||
| FaxNumber: | 8589665482 | ||||||||
| Practice Location | |||||||||
| Address1: | 4305 UNIVERSITY AVENUE, SUITE 150 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665484 | ||||||||
| FaxNumber: | 8589665484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2017 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAIN | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP & CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8589665824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RADY CHILDREN'S HOSPITAL-SAN DIEGO | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | CA | Y | Hospital Units | Psychiatric Unit |
No ID Information.