Basic Information
Provider Information | |||||||||
NPI: | 1871543215 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STANFORD HEALTH CARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STANFORD HOSPITAL AND CLINICS | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 PASTEUR DRIVE | ||||||||
Address2: |   | ||||||||
City: | STANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 943052200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507234000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 PASTEUR DR | ||||||||
Address2: |   | ||||||||
City: | STANFORD | ||||||||
State: | CA | ||||||||
PostalCode: | 943052200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507234000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 09/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AMIN-ABASSI | ||||||||
AuthorizedOfficialFirstName: | FATANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5109748592 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 070000662 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 1288115 | 05 | NV |   | MEDICAID | 940057626 | 05 | CO |   | MEDICAID | ZZR00441H | 05 | CA |   | MEDICAID | 116853300 | 05 | WY |   | MEDICAID | HSP40441H | 05 | CA |   | MEDICAID | 000A0561 | 05 | NM |   | MEDICAID | HS810P | 05 | AS |   | MEDICAID | 001188115 | 05 | NV |   | MEDICAID | ZZZP4328Z | 01 | CA | BLUE SHLD-FACULTY PRACTIC | OTHER | 034512 | 05 | OR |   | MEDICAID | 244848 | 05 | HI |   | MEDICAID | HS811P | 05 | AK |   | MEDICAID | 100643860B | 05 | KS |   | MEDICAID | 635477 | 05 | AZ |   | MEDICAID | 7102213 | 05 | WA |   | MEDICAID | ZZZA4309Z | 01 | CA | BLUE SHIELD | OTHER | 807248900 | 05 | ID |   | MEDICAID | HSC00441H | 05 | CA |   | MEDICAID |