Provider Demographics
NPI:1508561325
Name:SPECIALTY PEDIATRICS MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:SPECIALTY PEDIATRICS MEDICAL GROUP PLLC
Other - Org Name:SPECIALTY PEDIATRIC SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PANKAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-812-5040
Mailing Address - Street 1:8765 W KELTON LN
Mailing Address - Street 2:BLDG C1, STE-102
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5012
Mailing Address - Country:US
Mailing Address - Phone:480-812-5040
Mailing Address - Fax:520-552-6487
Practice Address - Street 1:8765 W KELTON LN STE C102
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5012
Practice Address - Country:US
Practice Address - Phone:480-812-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-03
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty