Basic Information
Provider Information | |||||||||
NPI: | 1457666802 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RADY CHILDREN'S HOSPITAL - SAN DIEGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KIDSTART SOUTH | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3020 CHILDRENS WAY | ||||||||
Address2: | MC 6013 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921234223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194205611 | ||||||||
FaxNumber: | 6194205531 | ||||||||
Practice Location | |||||||||
Address1: | 333 H ST | ||||||||
Address2: | SUITE 3010 | ||||||||
City: | CHULA VISTA | ||||||||
State: | CA | ||||||||
PostalCode: | 919105555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6194205611 | ||||||||
FaxNumber: | 6194205531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2010 | ||||||||
LastUpdateDate: | 10/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BIAL | ||||||||
AuthorizedOfficialFirstName: | VIRGINIA | ||||||||
AuthorizedOfficialMiddleName: | DILLON | ||||||||
AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8585761700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RADY CHILDREN'S HOSPITAL - SAN DIEGO | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: | 10/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 080000028 | CA | Y |   | Hospitals | General Acute Care Hospital | Children |
No ID Information.