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PED053303-33 RADY CHILDRENS HOSPITAL - SAN DIEGO (Terminated)
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Main Details
Name
RADY CHILDRENS HOSPITAL - SAN DIEGO
Subdivision Name
Gender Affirming Care* - Gender Affirming Care*
Type
Children's Hospital
Rural
No
340B ID
PED053303-33
Medicare Provider Number
053303
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/13/2021
Participating Start Date
7/1/2021
Participating Approval Date
5/6/2021
Last Recertification Date
8/28/2023
Termination Date
Termination Reason
10/1/2024
Hospital Outpatient facility no longer eligible
Contacts
Authorizing Official
Rady Children's Hospital San Diego
Charles Brendan Davis, Regional President Rady Children's Health San Diego and COO Rady Children's Hospital San Diego
(858) 966-4001
Primary Contact
Rady Children's Hospital San Diego
Chris Abe, VP, Operations
(858) 966-5968
Addresses
Street Address
8110 Birmingham Drive, San Diego, CA 92123
2nd Floor
San Diego, CA 92123
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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