1861449357 NPI number — GATEWAY PEDIATRICS PLLC

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 1861449357 NPI number — GATEWAY PEDIATRICS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GATEWAY PEDIATRICS PLLC
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:
1861449357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 S DOBSON RD
Provider Second Line Business Mailing Address:
B218
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85224-5667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-963-6668
Provider Business Mailing Address Fax Number:
480-963-6669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
655 S DOBSON RD
Provider Second Line Business Practice Location Address:
B218
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224-5667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-963-6668
Provider Business Practice Location Address Fax Number:
480-963-6669
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHANDRASEKHAR
Authorized Official First Name:
SUDHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-963-6668

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 649494 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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