1790850279 NPI number — PEDIATRIC SUBSPECIALTY FACULTY, INC.

Table of content: (NPI 1790850279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790850279 NPI number — PEDIATRIC SUBSPECIALTY FACULTY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SUBSPECIALTY FACULTY, 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:
CHOC PEDIATRIC SUBSPECIALTY FACULTY
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:
1790850279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
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:
715-094-8649
Provider Business Mailing Address Fax Number:
714-509-8374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 W LA VETA AVE
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:
92868-4203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-509-8649
Provider Business Practice Location Address Fax Number:
714-509-8374
Provider Enumeration Date:
11/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUHLMAN
Authorized Official First Name:
HALE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
714-532-8649

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , 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: 1265673743 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1447440417 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1902096969 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ411188Z . This is a "BLUE SHIELD/455" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1144468620 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356531313 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679714844 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1801086871 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1447440409 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194915157 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1538359591 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1740470707 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ08568Z . This is a "BLUE SHIELD/1310" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1093905051 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1306098652 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1356531321 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1467642421 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639310113 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1811187875 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ079907 . This is a "BLUE SHIELD/1201" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".