Provider Demographics
NPI:1801162854
Name:VALLEY OF THE SUN PEDIATRICS, P.C.
Entity type:Organization
Organization Name:VALLEY OF THE SUN PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:MATROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-362-1818
Mailing Address - Street 1:10200 W HAPPY VALLEY RD
Mailing Address - Street 2:STE 125
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-2878
Mailing Address - Country:US
Mailing Address - Phone:623-362-1818
Mailing Address - Fax:623-362-8095
Practice Address - Street 1:10200 W HAPPY VALLEY RD
Practice Address - Street 2:STE 125
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2878
Practice Address - Country:US
Practice Address - Phone:623-362-1818
Practice Address - Fax:623-362-8095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3855363LP0200X
AZAP4013363LP0200X
AZ33560208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ595173Medicaid
AZ645390Medicaid
AZ933780Medicaid