Provider Demographics
NPI:1528041811
Name:GROSSMONT HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:GROSSMONT HOSPITAL CORPORATION
Other - Org Name:SHARP GROSSMONT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-740-4648
Mailing Address - Street 1:8695 SPECTRUM CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1489
Mailing Address - Country:US
Mailing Address - Phone:858-499-3025
Mailing Address - Fax:858-499-4738
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000006282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050026OtherBLUE CROSS
CA350160OtherCCS
CAHSC30026GMedicaid
CAZZT30222GMedicaid
CAZZT40026GMedicaid
CAZZZA3704ZOtherBLUE SHIELD
CAZZT30222GMedicaid