Provider Demographics
NPI:1295863405
Name:STANFORD HOSPITAL AND CLINICS
Entity Type:Organization
Organization Name:STANFORD HOSPITAL AND CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEURODIAGNOSTIC LAB MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDELLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-723-0244
Mailing Address - Street 1:300 PASTEUR DRIVE
Mailing Address - Street 2:RM A343
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-5235
Mailing Address - Country:US
Mailing Address - Phone:650-498-7875
Mailing Address - Fax:650-498-7868
Practice Address - Street 1:300 PASTEUR DRIVE
Practice Address - Street 2:RM A343
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-5235
Practice Address - Country:US
Practice Address - Phone:650-498-7875
Practice Address - Fax:650-498-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY124930Medicaid
NONEMedicare UPIN
CA0PL124930Medicare ID - Type Unspecified