Basic Information
| Provider Information | |||||||||
| NPI: | 1265581086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STANFORD HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 PASTEUR DR | ||||||||
| Address2: | |||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943052200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507234000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 PASTEUR DR | ||||||||
| Address2: | |||||||||
| City: | STANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 943052200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507234000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AMIN-ABASSI | ||||||||
| AuthorizedOfficialFirstName: | FATANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5109748592 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STANFORD HEALTH CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 070000662 | CA | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 010207789 | 05 | VA | MEDICAID | 635477 | 05 | AZ | MEDICAID | 1288115 | 05 | NV | MEDICAID | 807248900 | 05 | ID | MEDICAID | HSM00441H | 05 | CA | MEDICAID | 050411 | 05 | TX | MEDICAID | 000A0561 | 05 | NM | MEDICAID | 034512 | 05 | OR | MEDICAID | ZZZA4309Z | 01 | CA | BLUE SHIELD OF CA | OTHER | 092494300 | 05 | FL | MEDICAID | 116853300 | 05 | WY | MEDICAID | 244848 | 05 | HI | MEDICAID | 940057626 | 05 | CO | MEDICAID | HS810P | 05 | AS | MEDICAID | 001188115 | 05 | NV | MEDICAID | 7102213 | 05 | WA | MEDICAID | HS811P | 05 | AR | MEDICAID |