Basic Information
| Provider Information | |||||||||
| NPI: | 1841277704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCRIPPS HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SCRIPPS MEMORIAL HOSPITAL LA JOLLA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589275328 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9888 GENESEE AVE | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584574123 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TANDE | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP CFO | ||||||||
| AuthorizedOfficialTelephone: | 8586787227 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCRIPPS HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 050324 | 01 | BLUE CROSS | OTHER | 27 | 01 | KAISER | OTHER | ZZT30324F | 01 | MEDICAL IN PATIENT ADMINI | OTHER | ZZT40324F | 01 | MEDICAL OUT PATIENT | OTHER | 050324B000000 | 01 | 1011 FUND ADMINISTERED BY | OTHER | 080000050 | 01 | STATE LICENSE | OTHER | ZZZA3701Z | 01 | BLUE SHIELD | OTHER | 164SHIJ | 01 | COUNTY MEDICAL SERVICES | OTHER | ZZT40324F | 01 | MEDICAL HMO OUT PATIENT | OTHER | 6151030 | 01 | AETNA | OTHER | HSC30324F | 01 | MEDICAL IN PATIENT | OTHER | SMLA | 01 | UNIVERSAL CARE | OTHER | HSC30324F | 01 | MEDICAL HMO IN PATIENT | OTHER |