Basic Information
| Provider Information | |||||||||
| NPI: | 1295407815 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 LOCKBOX 7642 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132810300 | ||||||||
| FaxNumber: | 8132810943 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033969148 | ||||||||
| FaxNumber: | 5032213701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | GANTT | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8132810300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.