Provider Demographics
NPI:1093855082
Name:NOAHS ARK FAMILY CLINIC CORP
Entity Type:Organization
Organization Name:NOAHS ARK FAMILY CLINIC CORP
Other - Org Name:NOAHS ARK PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT/CEO
Authorized Official - Phone:623-931-5001
Mailing Address - Street 1:7800 N 55TH AVE STE 106&107
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-1321
Mailing Address - Country:US
Mailing Address - Phone:623-931-5001
Mailing Address - Fax:623-931-5120
Practice Address - Street 1:7800 N 55TH AVE STE 106&107
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1321
Practice Address - Country:US
Practice Address - Phone:623-931-5001
Practice Address - Fax:623-931-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ337748Medicaid