1962673772 NPI number — PROVIDENCE PEDIATRICS

Table of content: (NPI 1962673772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962673772 NPI number — PROVIDENCE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE 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:
1962673772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9100 N CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85020-2430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-997-9898
Provider Business Mailing Address Fax Number:
602-997-9901

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9100 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85020-2430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-997-9898
Provider Business Practice Location Address Fax Number:
602-997-9901
Provider Enumeration Date:
03/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
LOURDES
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING
Authorized Official Telephone Number:
602-254-7077

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 531881 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com