Provider Demographics
NPI:1336335983
Name:GLENDALE PEDIATRICS LLC
Entity Type:Organization
Organization Name:GLENDALE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:SION
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-847-5300
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85311-0066
Mailing Address - Country:US
Mailing Address - Phone:623-847-5300
Mailing Address - Fax:
Practice Address - Street 1:6745 N 51ST DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3425
Practice Address - Country:US
Practice Address - Phone:623-847-5300
Practice Address - Fax:623-847-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ121568OtherAHCCCS