Healthcare Provider Details

I. General information

NPI: 1780927608
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-969-6118
  • Fax: 714-969-9594
Mailing address:
  • Phone: 714-969-6118
  • Fax: 714-969-9594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK KELLY
Title or Position: DIRECTOR, CS BUSINESS SERIVICES
Credential:
Phone: 714-509-7964