Provider Demographics
NPI:1053674564
Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Other - Org Name:RCHSD - CHILD AND ADOLESCENT PSYCHIATRY SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:SR VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-966-5824
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MC 5018
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-1700
Mailing Address - Fax:858-966-8470
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-8145
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-19
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000028273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5816515OtherMEDI-CAL