1588866453 NPI number — APACHE JUNCTION PEDIATRICS

Table of content: (NPI 1588866453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588866453 NPI number — APACHE JUNCTION PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APACHE JUNCTION PEDIATRICS
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:
1588866453
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:
1075 S IDAHO RD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
APACHE JUNCTION
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85219-6496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-889-1234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1075 S IDAHO RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
APACHE JUNCTION
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85219-6496
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-889-1234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRADLE
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
CERTIFIED PEDIATRIC NURSE PRACTIONE
Authorized Official Telephone Number:
480-889-1234

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  34596 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 27900 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 34587 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: AP0241 , 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: AZ0763370 . This is a "JB BC ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 088674 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 971409 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: F14456 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 524729 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0427690 . This is a "RL BC ID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 907397 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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