Provider Demographics
NPI:1063510279
Name:CHILDRENS MEDICAL CENTER OF BULLHEAD CITY, PLLC
Entity Type:Organization
Organization Name:CHILDRENS MEDICAL CENTER OF BULLHEAD CITY, PLLC
Other - Org Name:PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NAILA
Authorized Official - Middle Name:ASHRAF
Authorized Official - Last Name:TARIQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-758-0183
Mailing Address - Street 1:1225 HANCOCK RD
Mailing Address - Street 2:SUITE # B
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5948
Mailing Address - Country:US
Mailing Address - Phone:928-758-0183
Mailing Address - Fax:928-758-6665
Practice Address - Street 1:1225 HANCOCK RD
Practice Address - Street 2:SUITE # B
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5948
Practice Address - Country:US
Practice Address - Phone:928-758-0183
Practice Address - Fax:928-758-6665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31594208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788531Medicaid
H98492Medicare UPIN
CAZ 77102Medicare ID - Type Unspecified