Provider Demographics
NPI:1891904942
Name:ST JUDE HOSPITAL INC
Entity type:Organization
Organization Name:ST JUDE HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 31001-3017
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2767 E IMPERIAL HWY
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6713
Practice Address - Country:US
Practice Address - Phone:714-870-3510
Practice Address - Fax:714-870-3525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000173282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT30168FMedicaid
CAHSC30168FMedicaid
CAHSC30168FMedicaid
CAZZT30168FMedicaid