1013035716 NPI number — REGENTS OF THE UNIVERSITY OF CALIFORNIA

Table of content: (NPI 1013035716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013035716 NPI number — REGENTS OF THE UNIVERSITY OF CALIFORNIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENTS OF THE UNIVERSITY OF CALIFORNIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UCSD PEDIATRIC AND ADOLESCENT ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013035716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3860 CALLE FORTUNADA
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-502-1135
Provider Business Mailing Address Fax Number:
858-636-4319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 FROST STREET
Provider Second Line Business Practice Location Address:
STE 350
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-2771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-496-4800
Provider Business Practice Location Address Fax Number:
858-496-4850
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PICKERING
Authorized Official First Name:
BRETTEN
Authorized Official Middle Name:
DRAKE
Authorized Official Title or Position:
DIVISION CHIEF OF GENERAL ACADEMIC
Authorized Official Telephone Number:
858-496-4827

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0105540 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ69468Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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