Provider Demographics
NPI:1629076518
Name:SCOTTSDALE PEDIATRICS AND PEDIATRIC NEPHROLOGY
Entity Type:Organization
Organization Name:SCOTTSDALE PEDIATRICS AND PEDIATRIC NEPHROLOGY
Other - Org Name:AGAVE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJEEV
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-585-5200
Mailing Address - Street 1:7010 E. CHAUNCEY LN
Mailing Address - Street 2:SUITE 225
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-3117
Mailing Address - Country:US
Mailing Address - Phone:480-585-5200
Mailing Address - Fax:480-585-5233
Practice Address - Street 1:7010 E. CHAUNCEY LN
Practice Address - Street 2:SUITE 225
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-3117
Practice Address - Country:US
Practice Address - Phone:480-585-5200
Practice Address - Fax:480-585-5233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33323208000000X, 2080P0210X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103535Medicare ID - Type Unspecified