MEDICARE: RADY CHILDREN'S HOSPITAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS 14677	CA

General Provider Information

NPI Number	:	1033235718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADY CHILDREN'S HOSPITAL

Provider Business Mailing Address
First Line	:	3020 CHILDREN'S WAY
Second Line	:	MC 5014
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4282
Country	:	US
Telephone Number	:	858-966-4011
Fax Number	:	858-278-2365

Provider Business Practice Location Address
First Line	:	3020 CHILDRENS WAY
Second Line	:	MC 5014
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-966-4011
Fax Number	:	858-278-2365

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. CHARLES WILSON
Credential	:	MSW
Telephone Number	:	858-576-1700

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	08/22/2020

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