Provider Demographics
NPI:1093019150
Name:SPRINGFIELD MEDICAL LLC
Entity Type:Organization
Organization Name:SPRINGFIELD MEDICAL LLC
Other - Org Name:SPRINGFIELD PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLADIJI
Authorized Official - Middle Name:G
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-734-5509
Mailing Address - Street 1:36351 N GANTZEL RD STE 127
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-7329
Mailing Address - Country:US
Mailing Address - Phone:602-734-5509
Mailing Address - Fax:877-281-3385
Practice Address - Street 1:36351 N GANTZEL RD STE 127
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7329
Practice Address - Country:US
Practice Address - Phone:602-734-5509
Practice Address - Fax:877-281-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40162208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ358032Medicaid
AZ584197Medicaid