Provider Demographics
NPI:1184948416
Name:SKYLINE PEDIATRICS PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SKYLINE PEDIATRICS PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-834-5020
Mailing Address - Street 1:4930 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5615
Mailing Address - Country:US
Mailing Address - Phone:520-577-3333
Mailing Address - Fax:520-577-4685
Practice Address - Street 1:4930 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5615
Practice Address - Country:US
Practice Address - Phone:520-577-3333
Practice Address - Fax:520-577-4685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40475208000000X
AZ33544208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ932617Medicaid
AZ355175Medicaid
AZI31154Medicare UPIN