Provider Demographics
NPI:1851303994
Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Entity Type:Organization
Organization Name:RADY CHILDREN'S HOSPITAL - SAN DIEGO
Other - Org Name:CHILDREN'S HOSPITAL - SAN DIEGO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SR. VP/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-966-5824
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MAIL CODE 5002
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-4962
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:MAIL CODE 5002
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-4962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000028261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA053303OtherBLUE CROSS OF CALIFORNIA
CA053303OtherGIC INDEMNITY PLAN
CA053303OtherPINNACLE CLAIMS MANAGEMENT
HI53125301Medicaid
CACGP165365Medicaid
CAHSC30271FMedicaid
CA053303OtherWESTERN GROWERS
CACGP000355Medicaid
CAZZT30271FMedicaid
CAZZT40271FMedicaid
CAZZZH3702ZOtherBLUE SHIELD OF CALIFORNIA
CAHSC30271FMedicaid
M050271Medicare ID - Type UnspecifiedMEDICARE B
53303OtherUNICARE
HI53125301Medicaid
CAHSC30271FMedicaid