Provider Demographics
NPI:1275597221
Name:EAST VALLEY PEDIATRIC PULMONARY SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:EAST VALLEY PEDIATRIC PULMONARY SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PANESAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-614-6655
Mailing Address - Street 1:10250 N 92ND ST
Mailing Address - Street 2:308
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4510
Mailing Address - Country:US
Mailing Address - Phone:480-614-6655
Mailing Address - Fax:
Practice Address - Street 1:10250 N 92ND ST
Practice Address - Street 2:308
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4510
Practice Address - Country:US
Practice Address - Phone:480-614-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ264152080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
84654Medicare ID - Type Unspecified