Healthcare Provider Details

I. General information

NPI: 1023208030
Provider Name (Legal Business Name): STANFORD UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR ROOM G306
STANFORD CA
94305-2200
US

IV. Provider business mailing address

300 PASTEUR DR ROOM G306
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-7903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberA100154
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierA100154
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerMEDICAL BOARD OF CALIFORN

VIII. Authorized Official

Name: PAUL GRIMM
Title or Position: PROGRAM DIRECTOR
Credential: MD
Phone: 650-736-8423