Provider Demographics
NPI:1568493922
Name:UNIVERSITY OF CALIFORNIA IRVINE
Entity type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA IRVINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT AND CHIEF FINANCIAL
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:PERSEVERANCE
Authorized Official - Last Name:SIWABESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-456-5180
Mailing Address - Street 1:1500 S DOUGLASS RD
Mailing Address - Street 2:SUITE 200, RT 183
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-6911
Mailing Address - Country:US
Mailing Address - Phone:714-456-6245
Mailing Address - Fax:714-456-6715
Practice Address - Street 1:3751 KATELLA AVE
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3101
Practice Address - Country:US
Practice Address - Phone:562-598-1311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF CALIFORNIA IRVI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000142282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
002733-0001OtherPACIFICARE OF CALIFORNIA
CAHSC30551HMedicaid
050551B000000OtherSECTION 1011
443786740OtherAETNA US HEALTHCARE
ZZZA3017ZOtherBS OF CALIFORNIA
CAHSP40551HMedicaid
8202OtherHEALTH NET
000406OtherHUMANA
CAHSC30551HMedicaid