1861681355 NPI number — ST JUDE CARDIOTHORACIC SURGEONS

Table of content: (NPI 1861681355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861681355 NPI number — ST JUDE CARDIOTHORACIC SURGEONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JUDE CARDIOTHORACIC SURGEONS
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:
Provider Other Organization Name Type Code:
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:
1861681355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 W STEWART DR
Provider Second Line Business Mailing Address:
SUITE 503
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-3854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-997-2224
Provider Business Mailing Address Fax Number:
714-997-1187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W BASTANCHURY RD
Provider Second Line Business Practice Location Address:
SUITE 195
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-3419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-446-8866
Provider Business Practice Location Address Fax Number:
714-997-1187
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GATES
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
714-997-2224

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: FNP 36248 . This is a "STATE OF CA MEDICAL BOARD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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