Provider Demographics
NPI:1629219845
Name:RADY CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-966-7716
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-576-1700
Mailing Address - Fax:858-966-8495
Practice Address - Street 1:3020 CHILDRENS WAY # MC5081
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:858-576-1700
Practice Address - Fax:858-966-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22035103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZH3702ZOtherBLUE SHIELD GROUP PROVIDER NUMBER
CA053303Medicare UPIN