1184948416 NPI number — SKYLINE PEDIATRICS PROFESSIONAL CORPORATION

Table of content: (NPI 1184948416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184948416 NPI number — SKYLINE PEDIATRICS PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKYLINE PEDIATRICS PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SKYLINE PEDIATRICS PC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184948416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85740-6207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-577-3333
Provider Business Mailing Address Fax Number:
520-577-4685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4930 N 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85718-5615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-577-3333
Provider Business Practice Location Address Fax Number:
520-577-4685
Provider Enumeration Date:
03/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KOPAS
Authorized Official First Name:
BRICE
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
520-577-3333

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  33544 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 40475 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 355175 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 932617 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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