Provider Demographics
NPI:1134243330
Name:DESERT SUN PEDIATRICS PC
Entity type:Organization
Organization Name:DESERT SUN PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KNAPPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-563-1111
Mailing Address - Street 1:26224 N TATUM BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7500
Mailing Address - Country:US
Mailing Address - Phone:480-563-1111
Mailing Address - Fax:480-563-3044
Practice Address - Street 1:26224 N TATUM BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7500
Practice Address - Country:US
Practice Address - Phone:480-563-1111
Practice Address - Fax:480-563-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27009208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG5263OtherMERCY CARE GROUP
AZF07158OtherPHOENIX HEALTH PLAN GROUP