Basic Information
| Provider Information | |||||||||
| NPI: | 1801298708 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE QUEEN'S MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE QUEEN'S MEDICAL CENTER - WEST O'AHU | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 PUNCHBOWL ST | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086911000 | ||||||||
| FaxNumber: | 8085474044 | ||||||||
| Practice Location | |||||||||
| Address1: | 91-2141 FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967061993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086913000 | ||||||||
| FaxNumber: | 8086918165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | NOBRIGA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | KWH | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8086915957 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE QUEEN'S MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HI | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | K4091-1 | 01 | HI | HMSA | OTHER | S4091 | 01 | HI | HMSA | OTHER | D4091-7 | 01 | HI | HMSA | OTHER | H4091-8 | 01 | HI | HMSA | OTHER | N4091 | 01 | HI | HMSA | OTHER | Z4091-6 | 01 | HI | HMSA | OTHER | U4091-7 | 01 | HI | HMSA | OTHER | 490417-01 | 05 | HI | MEDICAID | B4091-1 | 01 | HI | HMSA | OTHER | N4091-4 | 01 | HI | HMSA | OTHER |