Provider Demographics
NPI:1003159500
Name:CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF ORANGE COUNTY
Other - Org Name:CS NEURO SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, BUSINESS SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-509-7964
Mailing Address - Street 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-8649
Mailing Address - Fax:714-509-8374
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-8649
Practice Address - Fax:714-509-8374
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HOSPITAL OR ORANGE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-03
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207T00000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty