Provider Demographics
NPI:1972754356
Name:DR. PHIL PEDIATRICS, P. A.
Entity Type:Organization
Organization Name:DR. PHIL PEDIATRICS, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-994-3256
Mailing Address - Street 1:4111 BARBARA LOOP SE STE A
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1068
Mailing Address - Country:US
Mailing Address - Phone:505-994-3256
Mailing Address - Fax:866-967-7905
Practice Address - Street 1:4111 BARBARA LOOP SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1068
Practice Address - Country:US
Practice Address - Phone:505-994-3256
Practice Address - Fax:866-967-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-266208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1437159993OtherINDIVIDUAL NPI
NM30197Medicaid
1437159993OtherINDIVIDUAL NPI