Provider Demographics
NPI:1265581086
Name:STANFORD HEALTH CARE
Entity type:Organization
Organization Name:STANFORD HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:FATANA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN-ABASSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-974-8592
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STANFORD HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-10
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000662283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010207789Medicaid
AZ635477Medicaid
NV1288115Medicaid
ID807248900Medicaid
CAHSM00441HMedicaid
TX050411Medicaid
NM000A0561Medicaid
OR034512Medicaid
CAZZZA4309ZOtherBLUE SHIELD OF CA
FL092494300Medicaid
WY116853300Medicaid
HI244848Medicaid
CO940057626Medicaid
ASHS810PMedicaid
NV001188115Medicaid
WA7102213Medicaid
ARHS811PMedicaid