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PED053303-05 RADY CHILDRENS HOSPITAL - SAN DIEGO (Terminated)
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Main Details
Name
RADY CHILDRENS HOSPITAL - SAN DIEGO
Subdivision Name
Urgent Care East County
Type
Children's Hospital
Rural
No
340B ID
PED053303-05
Medicare Provider Number
053303
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
10/15/2014
Participating Start Date
1/1/2015
Participating Approval Date
12/10/2014
Last Recertification Date
8/26/2022
Termination Date
Termination Reason
10/1/2023
Site closure
Contacts
Authorizing Official
Rady Children's Hospital San Diego
Nicholas Matthew Holmes, Senior VP, Chief Operating Officer
(858) 966-5948
Primary Contact
Rady Children's Hospital San Diego
Chris Abe, VP, Operations
(858) 966-5968
Addresses
Street Address
5565 Grossmont Center Drive, Bldg 2, Suite 2
La Mesa, CA 91942
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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