Basic Information
| Provider Information | |||||||||
| NPI: | 1104205335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RADY CHILDREN'S HOSPITAL SAN DIEGO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 CITRACADO PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920256428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602949270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 CITRACADO PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920256428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602949270 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2015 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOGAN | ||||||||
| AuthorizedOfficialFirstName: | MONA | ||||||||
| AuthorizedOfficialMiddleName: | ELAINE | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERN | ||||||||
| AuthorizedOfficialTelephone: | 7604431416 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | Y | Hospitals | General Acute Care Hospital | Children |
No ID Information.