Basic Information
| Provider Information | |||||||||
| NPI: | 1033112230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JUDE CHILDRENS RESEARCH HOSPITAL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 DANNY THOMAS PLACE MS 0515 | ||||||||
| Address2: | ST JUDE CHILDRENS RESEARCH HOSPITAL | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015956863 | ||||||||
| FaxNumber: | 9015953842 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 DANNY THOMAS PL | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | KEEL | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9015952916 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | 843 | TN | N | Suppliers | Pharmacy | Clinic Pharmacy | 282NC2000X | 0000000113 | TN | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 443302 | 05 | TN | MEDICAID |