Provider Demographics
NPI:1417121393
Name:PHOENIX CHILDREN'S HOSPITAL, INC.
Entity Type:Organization
Organization Name:PHOENIX CHILDREN'S HOSPITAL, INC.
Other - Org Name:PHOENIX CHILDREN'S MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP, MANAGED CARE & PAYOR STRATEGY
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:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5425 E BELL RD STE 145
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6010
Practice Address - Country:US
Practice Address - Phone:602-933-5730
Practice Address - Fax:602-933-2483
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CHILDREN'S HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC7349208000000X
AZSH3107208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ876253Medicaid
AZ876253Medicaid