Basic Information
| Provider Information | |||||||||
| NPI: | 1790850279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC SUBSPECIALTY FACULTY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHOC PEDIATRIC SUBSPECIALTY FACULTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 455 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7150948649 | ||||||||
| FaxNumber: | 7145098374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145098649 | ||||||||
| FaxNumber: | 7145098374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUHLMAN | ||||||||
| AuthorizedOfficialFirstName: | HALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7145328649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1265673743 | 05 | CA | MEDICAID | 1447440417 | 05 | CA | MEDICAID | 1902096969 | 05 | CA | MEDICAID | ZZZ411188Z | 01 | CA | BLUE SHIELD/455 | OTHER | 1144468620 | 05 | CA | MEDICAID | 1356531313 | 05 | CA | MEDICAID | 1679714844 | 05 | CA | MEDICAID | 1801086871 | 05 | CA | MEDICAID | 1447440409 | 05 | CA | MEDICAID | 1194915157 | 05 | CA | MEDICAID | 1538359591 | 05 | CA | MEDICAID | 1740470707 | 05 | CA | MEDICAID | ZZZ08568Z | 01 | CA | BLUE SHIELD/1310 | OTHER | 1093905051 | 05 | CA | MEDICAID | 1306098652 | 05 | CA | MEDICAID | 1356531321 | 05 | CA | MEDICAID | 1467642421 | 05 | CA | MEDICAID | 1639310113 | 05 | CA | MEDICAID | 1811187875 | 05 | CA | MEDICAID | ZZZ079907 | 01 | CA | BLUE SHIELD/1201 | OTHER | 1003054420 | 05 | CA | MEDICAID | 1386834349 | 05 | CA | MEDICAID | ZZZ08133Z | 01 | CA | BLUE SHIELD/1120 | OTHER |