Provider Demographics
NPI:1083606529
Name:CROSSROADS PEDIATRICS PLLC
Entity Type:Organization
Organization Name:CROSSROADS PEDIATRICS PLLC
Other - Org Name:PAX LUMENA PEDIATRICS PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-722-1180
Mailing Address - Street 1:655 S. DOBSON RD
Mailing Address - Street 2:SUITE B-218
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5671
Mailing Address - Country:US
Mailing Address - Phone:480-722-1180
Mailing Address - Fax:480-722-1187
Practice Address - Street 1:655 S. DOBSON RD.
Practice Address - Street 2:SUITE B-218
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5671
Practice Address - Country:US
Practice Address - Phone:480-722-1180
Practice Address - Fax:480-722-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16602208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ247454001Medicaid
AZ247454001Medicaid