1104818822 NPI number — ARIZONA CHILDRENS SURGERY PC

Table of content: (NPI 1104818822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104818822 NPI number — ARIZONA CHILDRENS SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA CHILDRENS SURGERY 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:
EAST VALLEY PEDIATRIC SURGERY
Provider Other Organization Name Type Code:
4
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:
1104818822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85274-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-464-9400
Provider Business Mailing Address Fax Number:
480-464-9401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1432 S DOBSON RD
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85202-4768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-464-9400
Provider Business Practice Location Address Fax Number:
480-464-9401
Provider Enumeration Date:
08/18/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GRISONI
Authorized Official First Name:
ENRIQUE
Authorized Official Middle Name:
RICARDO
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
480-512-6514

Provider Taxonomy Codes

  • Taxonomy code: 2086S0120X , with the licence number:  28876 , 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)





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