1679703441 NPI number — PHOENIX CHILDREN'S MEDICAL GROUP

Table of content: (NPI 1679703441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679703441 NPI number — PHOENIX CHILDREN'S MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX CHILDREN'S MEDICAL GROUP
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:
6
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:
1679703441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2108 E THOMAS RD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20325 N 51ST AVE
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-5674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-933-0003
Provider Business Practice Location Address Fax Number:
602-933-6152
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FAROUGH
Authorized Official First Name:
RAHEEL
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP, MANAGED CARE & PAYOR STRATEGY
Authorized Official Telephone Number:
602-933-3548

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  SH3107 , 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: 876253 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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