1093905051 NPI number — PSF ICD

Table of content: (NPI 1093905051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093905051 NPI number — PSF ICD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSF ICD
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:
PEDIATRIC SUBSPECIALTY FACULTY, INC.
Provider Other Organization Name Type Code:
5
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:
1093905051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-3835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-516-4295
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
455 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-516-4295
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FARACE
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
714-516-4295

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0090390 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1790850279 . This is a "CORPORATE NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR009039F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".