MEDICARE: KIDS CRITICAL CARE MEDICAL GROUP INC

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	282NC2000X	Children's Hospital	047879	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GR0046500	OTHER	CA	MEDICAL

General Provider Information

NPI Number	:	1528144763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS CRITICAL CARE MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	PO BOX 2217
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92837
Country	:	US
Telephone Number	:	714-999-5144
Fax Number	:	714-999-5143

Provider Business Practice Location Address
First Line	:	1111 WEST LA PALMA AVE
Second Line	:	ANAHEIM MEMORIAL MEDICAL CENTER
City	:	ANAHEIM
State	:	CA
Zip	:	92801-2881
Country	:	US
Telephone Number	:	714-999-5144
Fax Number	:	714-999-5143

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SANDY S SHAW
Credential	:	MD
Telephone Number	:	714-999-5144

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	08/22/2020

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