Basic Information
Provider Information | |||||||||
NPI: | 1982793139 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHRINERS HOSPITALS FOR CHILDREN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8500 | ||||||||
Address2: | LOCKBOX #7642 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191787642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032943230 | ||||||||
FaxNumber: | 5032213701 | ||||||||
Practice Location | |||||||||
Address1: | 3101 SW SAM JACKSON PARK RD | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972393009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032943230 | ||||||||
FaxNumber: | 5032213701 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 09/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GANTT | ||||||||
AuthorizedOfficialFirstName: | JERRY | ||||||||
AuthorizedOfficialMiddleName: | G. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8132810300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 394874 | OR | Y |   | Hospitals | General Acute Care Hospital | Children |
ID Information
ID | Type | State | Issuer | Description | 1982793139 | 05 | ID |   | MEDICAID | HS10RIP | 05 | AK |   | MEDICAID | 2015176 | 05 | WA |   | MEDICAID | 271154 | 05 | OR |   | MEDICAID |