Provider Demographics
NPI:1962673772
Name:PROVIDENCE PEDIATRICS
Entity Type:Organization
Organization Name:PROVIDENCE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-254-7077
Mailing Address - Street 1:9100 N CENTRAL AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2430
Mailing Address - Country:US
Mailing Address - Phone:602-997-9898
Mailing Address - Fax:602-997-9901
Practice Address - Street 1:9100 N CENTRAL AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2430
Practice Address - Country:US
Practice Address - Phone:602-997-9898
Practice Address - Fax:602-997-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ531881Medicaid