Basic Information
Provider Information | |||||||||
NPI: | 1750614764 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RADY CHILDREN'S HOSPITAL-SAN DIEGO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RADY C.E.S. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3665 KEARNY VILLA ROAD | ||||||||
Address2: | PSYCHIATRY - MC 5018 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 92123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8589665832 | ||||||||
FaxNumber: | 8589668470 | ||||||||
Practice Location | |||||||||
Address1: | 3665 KEARNY VILLA ROAD, SUITE 165 | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 92123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8589665832 | ||||||||
FaxNumber: | 8589668470 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2009 | ||||||||
LastUpdateDate: | 09/09/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROUX | ||||||||
AuthorizedOfficialFirstName: | ROGER | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT CFO | ||||||||
AuthorizedOfficialTelephone: | 8585761700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | Y |   | Hospital Units | Psychiatric Unit |   |
No ID Information.