Provider Demographics
NPI:1487814240
Name:PHOENIX CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:PHOENIX CHILDREN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP, MANAGED CARE & PAYER 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 1:5131 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2799
Practice Address - Country:US
Practice Address - Phone:602-933-0002
Practice Address - Fax:602-933-6216
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX CHILDREN'S HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-13
Last Update Date:2023-05-22
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
AZ876253Medicaid