Provider Demographics
NPI:1528195716
Name:CHILDRENS HOSPITAL OF ORANGE COUNTY
Entity Type:Organization
Organization Name:CHILDRENS HOSPITAL OF ORANGE COUNTY
Other - Org Name:CHOC CLINIC COSTA MESA
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CADOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:714-289-4818
Mailing Address - Street 1:136 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2818
Mailing Address - Country:US
Mailing Address - Phone:714-589-4861
Mailing Address - Fax:
Practice Address - Street 1:136 BROADWAY
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2818
Practice Address - Country:US
Practice Address - Phone:714-589-4861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACMM71081F261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71081FOtherGROUP MEDI-CAL ID NUMBER