Healthcare Provider Details

I. General information

NPI: 1528144763
Provider Name (Legal Business Name): KIDS CRITICAL CARE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 WEST LA PALMA AVE ANAHEIM MEMORIAL MEDICAL CENTER
ANAHEIM CA
92801-2881
US

IV. Provider business mailing address

PO BOX 2217
FULLERTON CA
92837
US

V. Phone/Fax

Practice location:
  • Phone: 714-999-5144
  • Fax: 714-999-5143
Mailing address:
  • Phone: 714-999-5144
  • Fax: 714-999-5143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number047879
License Number StateCA

VIII. Authorized Official

Name: SANDY S SHAW
Title or Position: PRESIDENT
Credential: MD
Phone: 714-999-5144