Provider Demographics
NPI:1073102976
Name:BETHESDA PEDIATRICS OF QUEEN CREEK
Entity Type:Organization
Organization Name:BETHESDA PEDIATRICS OF QUEEN CREEK
Other - Org Name:MAIN STREET PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-792-9200
Mailing Address - Street 1:22707 S ELLSWORTH RD STE H101
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-7568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 S 63RD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1620
Practice Address - Country:US
Practice Address - Phone:480-792-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-14
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ538751Medicaid