1528144763 NPI number — KIDS CRITICAL CARE MEDICAL GROUP INC

Table of content: (NPI 1528144763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528144763 NPI number — KIDS CRITICAL CARE MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS CRITICAL CARE MEDICAL GROUP INC
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:
KIDS CARE MED GROUP INC
Provider Other Organization Name Type Code:
4
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:
1528144763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-999-5144
Provider Business Mailing Address Fax Number:
714-999-5143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 WEST LA PALMA AVE
Provider Second Line Business Practice Location Address:
ANAHEIM MEMORIAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92801-2881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-999-5144
Provider Business Practice Location Address Fax Number:
714-999-5143
Provider Enumeration Date:
10/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHAW
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-999-5144

Provider Taxonomy Codes

  • Taxonomy code: 282NC2000X , with the licence number:  047879 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0046500 . This is a "MEDICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".