Basic Information
Provider Information
NPI: 1629219845
EntityType: 2
ReplacementNPI:  
OrganizationName: RADY CHILDREN'S HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3020 CHILDRENS WAY
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921234223
CountryCode: US
TelephoneNumber: 8585761700
FaxNumber: 8589668495
Practice Location
Address1: 3020 CHILDRENS WAY # MC5081
Address2:  
City: SAN DIEGO
State: CA
PostalCode: 921234223
CountryCode: US
TelephoneNumber: 8585761700
FaxNumber: 8589668495
Other Information
ProviderEnumerationDate: 03/18/2009
LastUpdateDate: 03/18/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FOREST
AuthorizedOfficialFirstName: CHRISTINE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CONTRACT SPECIALIST
AuthorizedOfficialTelephone: 8589667716
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XPSY22035CAY193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistClinical

ID Information
IDTypeStateIssuerDescription
ZZZH3702Z01CABLUE SHIELD GROUP PROVIDER NUMBEROTHER


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