Provider Demographics
NPI:1376944298
Name:PHOENIX CHILDREN'S HOSPITAL
Entity Type:Organization
Organization Name:PHOENIX CHILDREN'S HOSPITAL
Other - Org Name:PHOENIX CHILDREN'S HOSPITAL SPECIALTY CLINIC MERCY GILBERT
Other - Org Type:Other Name
Authorized Official - Title/Position:VP, MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:RAHEEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-933-3548
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7761
Mailing Address - Country:US
Mailing Address - Phone:602-933-1815
Mailing Address - Fax:
Practice Address - Street 1:3420 S MERCY RD
Practice Address - Street 2:STE 121
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0419
Practice Address - Country:US
Practice Address - Phone:602-933-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSH3107261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ706707Medicaid
AZ876253Medicaid