Provider Demographics
NPI:1164882999
Name:CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL OF ORANGE COUNTY
Other - Org Name:CS CARDIOTHORACIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE SUPPORT
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:714-509-7861
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 OF ORANGE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-07
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RC0000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty