Healthcare Provider Details

I. General information

NPI: 1750458485
Provider Name (Legal Business Name): RADY CHILDREN'S HOSPITAL SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8010 FROST ST. STE 200
SAN DIEGO CA
92123
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC5023
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5817
  • Fax: 858-966-8528
Mailing address:
  • Phone: 858-966-5817
  • Fax: 858-966-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberPSY11584
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number080000028
License Number StateCA

VIII. Authorized Official

Name: DR. JEFFERY R. OLSON
Title or Position: SUPERVISOR DEV SRVS OPERATIONS
Credential: PH.D.
Phone: 858-966-5416