1902888027 NPI number — GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902888027 NPI number — GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC
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:
Provider Other Organization Name Type Code:
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:
1902888027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10320 W MCDOWELL RD
Provider Second Line Business Mailing Address:
#L1238
Provider Business Mailing Address City Name:
AVONDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85323-4863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-643-9233
Provider Business Mailing Address Fax Number:
623-643-9234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 E BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85042-6510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-824-4228
Provider Business Practice Location Address Fax Number:
602-824-4259
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHICK
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
623-643-9233

Provider Taxonomy Codes

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

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

  • Identifier: 961004 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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