Provider Demographics
NPI:1629325378
Name:ACTIVE KIDS PEDIATRICS, PC
Entity Type:Organization
Organization Name:ACTIVE KIDS PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN, CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:ROSCH
Authorized Official - Last Name:BARNES CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-783-8960
Mailing Address - Street 1:15215 S 48TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-9142
Mailing Address - Country:US
Mailing Address - Phone:480-783-8960
Mailing Address - Fax:480-783-8967
Practice Address - Street 1:15215 S 48TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-9142
Practice Address - Country:US
Practice Address - Phone:480-783-8960
Practice Address - Fax:480-783-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZA32674261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service