Basic Information
| Provider Information | |||||||||
| NPI: | 1093712374 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL CAMINO HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EL CAMINO HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 GRANT RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940404302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509407000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 GRANT RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN VIEW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940404302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509407000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOO | ||||||||
| AuthorizedOfficialFirstName: | MING-RONG | ||||||||
| AuthorizedOfficialMiddleName: | CHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE & REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6509407247 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 070000660 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSC30308H | 05 | CA | MEDICAID | HSP30308H | 05 | CA | MEDICAID | HSP40308H | 05 | CA | MEDICAID | LTC55593F | 05 | CO | MEDICAID | CDC02659G | 05 | CA | MEDICAID | ZZZA43042 | 01 | CA | BLUE SHIELD | OTHER | PBH345400 | 05 | CA | MEDICAID |