=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295497972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JUDES MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2021
-----------------------------------------------------
Last Update Date | 10/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SAINT JUDES MEDICAL CENTER HEROICO COLEGIO MILITAR SN CENTRO
-----------------------------------------------------
City | TODO SANTOS
-----------------------------------------------------
State | BCS
-----------------------------------------------------
Zip | 23300
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone | 612-145-0600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9169 W STATE ST # 2133
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. IAN FISCHMAN
-----------------------------------------------------
Credential | MANAGER
-----------------------------------------------------
Telephone | 650-417-1127
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 282NR1301X
-----------------------------------------------------
Taxonomy Name | Rural Acute Care Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------