Covered Entity Details

PED053303-10 RADY CHILDRENS HOSPITAL - SAN DIEGO (Active) - information as of 4/25/2025 6:34:40 PM

Main Details

Name

RADY CHILDRENS HOSPITAL - SAN DIEGO

Subdivision Name

Genetics

Type

Children's Hospital

Rural

340B ID

PED053303-10

Medicare Provider Number

053303

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/15/2014

Participating Start Date

1/1/2015

Participating Approval Date

12/10/2014

Last Recertification Date

8/28/2024

Contacts

Authorizing Official

Rady Children's Hospital San Diego
Charles Brendan Davis, Interim Chief Operating Officer
(858) 966-4001

Primary Contact

Rady Children's Hospital San Diego
Chris Abe, VP, Operations
(858) 966-5968

Addresses

Street Address

7920 Frost Street
Suite 200
San Diego, CA 92123

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	1710065933	1710065933,1851303994,1669617197

Shipping Addresses

Shipping Address 1

Rady Children's Hospital
3020 Children's Way
San Diego, CA 92123

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED053303-01	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Sanford Pediatric Clinic - Urgent Care Oceanside	3605 Vista Way, Suite 172	Oceanside	CA	Active
PED053303-02	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	URGENT CARE MID CITY	4305 UNIVERSITY AVE	SAN DIEGO	CA	Active
PED053303-03	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Urgent Care North County	2125 Citracado Parkway	Escondido	CA	Active
PED053303-04	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Pulmonology	3030 Children's Way	San Diego	CA	Active
PED053303-05	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Urgent Care East County	5565 Grossmont Center Drive, Bldg 2, Suite 2	La Mesa	CA	Terminated
PED053303-06	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Dermatology	7910 Frost Street Suite 120	San Diego	CA	Active
PED053303-07	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Otolaryngology	3030 Children's Way	San Diego	CA	Active
PED053303-08	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Rheumatology / Rheumatology	3030 Children's Way	San Diego	CA	Active
PED053303-10	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Genetics	7920 Frost Street	San Diego	CA	Active
PED053303-11	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Gastroenterology	3030 Children's Way	San Diego	CA	Active
PED053303-14	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Urology	7920 Frost Street	San Diego	CA	Active
PED053303-16	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Orthopedics	3030 Children's Way	San Diego	CA	Active
PED053303-21	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Pediatric Gynecology / Pediatric Gynecology	7920 Frost St Suite #200	San Diego	CA	Active
PED053303-22	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Plastics / Plastics	7920 Frost St Suite #200	San Diego	CA	Active
PED053303-23	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Proton Beam Therapy Clinic	9730 SUMMERS RIDGE RD	SAN DIEGO	CA	Active
PED053303-24	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Pulmonary Function Lab - Pulmonary Function Lab	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-25	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Solid Organ Transplant - Liver Transplant	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-26	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Cystic Fibrosis - Cystic Fibrosis	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-27	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Physiatry - Rehab Medicine	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-28	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Infectious Disease - Infectious Disease	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-29	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Allergy - Allergy	Rady Children's Hospital San Diego	San Diego	CA	Active
PED053303-30	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Palliative Care and Pain - Supportive Care	Rady Children's Hospital San Diego	San Diego	CA	Terminated
PED053303-31	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Endocrinology - Endocrinology	3030 Children's Way	San Diego	CA	Active
PED053303-32	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	UC South Bay - UC South Bay	386 East H Street	Chula Vista	CA	Active
PED053303-33	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Gender Affirming Care* - Gender Affirming Care*	8110 Birmingham Drive, San Diego, CA 92123	San Diego	CA	Terminated
PED053303-34	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Adolescent Medicine - Adolescent Medicine	8110 Birmingham Drive, San Diego, CA 92123	San Diego	CA	Terminated
PED053303-35	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	RADY CHILDREN'S HOSPITAL - SAN DIEG - Neurology	3030 CHILDRENS WAY	SAN DIEGO	CA	Active
PED053303-36	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Nephrology - Nephrology	3020 Children's Way	San Diego	CA	Active
PED053303-37	Child	PED	RADY CHILDRENS HOSPITAL - SAN DIEGO	Kidney Transplant - Kidney Transplant	3020 Children's Way	San Diego	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 12:08:25 PM	8/28/2024 2:51:59 PM	8/28/2024 2:51 PM
Contacts	Authorizing Official	Update	Change Request	Holmes, Nicholas Matthew Senior VP, Chief Operating Officer Rady Children's Hospital San Diego 8589665948	Davis, Charles Brendan Interim Chief Operating Officer Rady Children's Hospital San Diego 8589664001	2/12/2024 8:32 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 12:08:30 PM	8/28/2023 12:08:25 PM	8/28/2023 12:08 PM
Details	Last Recertification Date	Update	Recertification	8/16/2021 6:56:55 PM	8/29/2022 12:08:30 PM	8/29/2022 12:08 PM
Details	Last Recertification Date	Update	Recertification	9/7/2020 10:26:40 AM	8/16/2021 6:56:55 PM	8/16/2021 6:56 PM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/7/2020 10:26 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/7/2020 10:26 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/7/2020 10:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1053490797 ( )		9/7/2020 10:26 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1699853713 ( )		9/7/2020 10:26 AM
Contacts	Primary Contact	Update	Recertification	Sey, Mark Pharmicist in Chief Rady Childrens Hospital 8589668023	Abe, Chris VP, Operations Rady Children's Hospital San Diego 8589665968	9/7/2020 10:26 AM
Details	Last Recertification Date	Update	Recertification	8/26/2019 1:46:55 PM	9/7/2020 10:26:40 AM	9/7/2020 10:26 AM
Details	Last Recertification Date	Update	Recertification	9/7/2018 4:53:31 PM	8/26/2019 1:46:55 PM	8/26/2019 1:46 PM
Contacts	Primary Contact	Update	Change Request	Scott, Jamie Leigh 340B Program Manager Rady Children's Hospital 8589661700-5024	Sey, Mark Pharmicist in Chief Rady Childrens Hospital 8589668023	4/22/2019 1:22 PM
Contacts	Primary Contact	Update	Change Request	Abe, Chris Senior Director Ancillary and Support Services Rady Children's Hospital San Diego 8589665968	Scott, Jamie Leigh 340B Program Manager Rady Children's Hospital 8589661700-5024	12/24/2018 3:11 PM
Details	Last Recertification Date	Update	Recertification	11/28/2017 6:56:09 PM	9/7/2018 4:53:31 PM	9/7/2018 4:53 PM
Contacts	Authorizing Official	Update	AO Change Request	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589664006	Holmes, Nicholas Matthew Senior VP, Chief Operating Officer Rady Children's Hospital San Diego 8589665948	4/12/2018 7:23 AM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/28/2017 6:56:09 PM	11/28/2017 6:56 PM
Contacts	Authorizing Official	Update	Profile Change Request	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589666004	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589664006	10/25/2017 2:20 PM
Contacts	Signed By	Update	Profile Change Request	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589666004	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589664006	10/25/2017 2:20 PM
Contacts	Primary Contact	Update	Recertification	Abe, Chris Senior Director Ancillary and Support Services 8589665968	Abe, Chris Senior Director Ancillary and Support Services Rady Children's Hospital San Diego 8589665968	10/25/2017 2:19 PM
Contacts	Authorizing Official	Update		Norton, Margareta E. Chief Operating Officer 8589666004	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589666004	10/25/2017 2:09 PM
Contacts	Signed By	Update		Norton, Margareta E. Chief Operating Officer 8589666004	Norton, Margareta E. Chief Operating Officer Rady Children's Hospital-San Diego 8589666004	10/25/2017 2:09 PM
Contacts	Authorizing Official	Insert			Norton, Margareta E. Chief Operating Officer 8589666004	8/30/2017 12:44 PM
Contacts	Signed By	Insert			Norton, Margareta E. Chief Operating Officer 8589666004	8/30/2017 12:44 PM
Contacts	Primary Contact	Insert			Abe, Chris Senior Director Ancillary and Support Services 8589665968	8/30/2017 12:44 PM
Addresses	Main Address	Insert			7920 Frost Street Suite 200 San Diego, CA 92123	7/7/2017 11:12 AM
Addresses	Shipping Address	Insert			Rady Children's Hospital 3020 Children's Way San Diego, CA 92123	7/7/2017 11:12 AM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 12:47 PM
Details	Last Recertification Date	Update			9/2/2015 12:00:00 AM	9/2/2015 3:30 PM
Medicaid Billing	NPI: Number	Insert			1851303994	12/12/2014 4:09 PM
Medicaid Billing	NPI: Number	Insert			1669617197	12/12/2014 4:09 PM
Medicaid Billing	NPI: Number	Insert			1053490797	12/12/2014 4:09 PM
Medicaid Billing	NPI: Number	Insert			1699853713	12/12/2014 4:09 PM
Dates	Participating Approval Date	Update			12/10/2014 12:00:00 AM	12/10/2014 3:05 PM
Details	State	Update		Pending	Active	12/10/2014 3:05 PM
Dates	Start Date	Update			1/1/2015 12:00:00 AM	12/10/2014 3:05 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_47506	PED053303-10	11/26/2014 9:21 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_47506	10/15/2014 12:57 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/15/2014 12:57 PM
Medicaid Billing	Medicaid: Number	Insert			1710065933	10/15/2014 12:57 PM
Medicaid Billing	Medicaid: State	Insert			CA	10/15/2014 12:57 PM
Medicaid Billing	NPI: Number	Insert			1710065933	10/15/2014 12:57 PM
Details	Last Recertification Date	Insert				10/15/2014 12:57 PM
Details	Grant Number	Insert				10/15/2014 12:57 PM
Details	340B ID	Insert				10/15/2014 12:57 PM
Details	Is Authorizing Official EHB Data	Insert				10/15/2014 12:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/15/2014 12:57 PM
Details	Medicare Provider Number	Insert			053303	10/15/2014 12:57 PM
Details	Entity Name	Insert			RADY CHILDRENS HOSPITAL - SAN DIEGO	10/15/2014 12:57 PM
Details	Program Code	Insert			PED	10/15/2014 12:57 PM
Details	Entity Subname	Insert			Genetics	10/15/2014 12:57 PM
Dates	Participating Approval Date	Insert				10/15/2014 12:57 PM
Details	State	Insert			Pending	10/15/2014 12:57 PM
Dates	Registration Date	Insert			10/15/2014 12:00:00 AM	10/15/2014 12:57 PM
Dates	Signed By Date	Insert			10/15/2014 12:00:00 AM	10/15/2014 12:57 PM
Dates	Start Date	Insert				10/15/2014 12:57 PM
Terminations	Termination Comments	Insert				10/15/2014 12:57 PM
Terminations	Termination Date	Insert				10/15/2014 12:57 PM
Terminations	Termination Effective Date	Insert				10/15/2014 12:57 PM
Terminations	Termination Reason	Insert				10/15/2014 12:57 PM