Provider Demographics
NPI:1003096801
Name:CHILDREN'S MEDICAL GROUP, LTD
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:T
Authorized Official - Last Name:LARDIZABAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-843-4149
Mailing Address - Street 1:5757 W THUNDERBIRD RD
Mailing Address - Street 2:E 255
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4641
Mailing Address - Country:US
Mailing Address - Phone:602-843-4149
Mailing Address - Fax:602-843-3224
Practice Address - Street 1:5757 W THUNDERBIRD RD
Practice Address - Street 2:E 255
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4641
Practice Address - Country:US
Practice Address - Phone:602-843-4149
Practice Address - Fax:602-843-3224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ260852Medicaid