MEDICARE: UC REGENTS UCI DEPT OF PEDIATRICS

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	207SG0205X	Ph.D. Medical Genetics Physician
2	208000000X	Pediatrics Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	CG7642	OTHER	CA	RAILROAD MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ54107Z	OTHER	CA	BLUE SHIELD GROUP #
2	ZZZ54113Z	OTHER	CA	BLUE SHIELD GROUP #
3	ZZZ54104Z	OTHER	CA	BLUE SHIELD
4	ZZZ54109Z	OTHER	CA	BLUE SHIELD GROUP #
5	ZZZ54112Z	OTHER	CA	BLUE SHIELD GROUP #
6	ZZZ04921Z	OTHER	CA	BLUE SHIELD GROUP #
8	GR0029040	OTHER	CA	MEDI-CAL GROUP #
9	ZZZ17751Z	OTHER	CA	BLUE SHIELD GROUP #
10	ZZZ06275Z	OTHER	CA	BLUE SHIELD GROUP #
11	ZZZ54114Z	OTHER	CA	BLUE SHIELD GROUP #
12	ZZZ54103Z	OTHER	CA	BLUE SHIELD GROUP #
13	ZZZ54106Z	OTHER	CA	BLUE SHIELD GROUP #

General Provider Information

NPI Number	:	1235187311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UC REGENTS UCI DEPT OF PEDIATRICS

Provider Business Mailing Address
First Line	:	PO BOX 31001-2494
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-2494
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 THE CITY DR S
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868
Country	:	US
Telephone Number	:	714-456-8068
Fax Number	:	714-456-3765

Authorized Official
Title or Position	:	UPS PROVIDER RELATIONS
Name	:	UCI HEALTH PROVIDER RELATIONS
Credential	:
Telephone Number	:	714-456-2986

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	01/30/2019

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