1972754356 NPI number — DR. PHIL PEDIATRICS, P. A.

Table of content: (NPI 1972754356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972754356 NPI number — DR. PHIL PEDIATRICS, P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. PHIL PEDIATRICS, P. A.
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:
1972754356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4111 BARBARA LOOP SE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87124-1068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-994-3256
Provider Business Mailing Address Fax Number:
866-967-7905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4111 BARBARA LOOP SE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-1068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-994-3256
Provider Business Practice Location Address Fax Number:
866-967-7905
Provider Enumeration Date:
10/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PERKINS
Authorized Official First Name:
KALIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
505-994-3256

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  86-266 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1437159993 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30197 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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