Healthcare Provider Details

I. General information

NPI: 1003096801
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD E 255
GLENDALE AZ
85306-4641
US

IV. Provider business mailing address

5757 W THUNDERBIRD RD E 255
GLENDALE AZ
85306-4641
US

V. Phone/Fax

Practice location:
  • Phone: 602-843-4149
  • Fax: 602-843-3224
Mailing address:
  • Phone: 602-843-4149
  • Fax: 602-843-3224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AGNES T LARDIZABAL
Title or Position: PHYSICIAN/PRESIDENT
Credential: M.D.
Phone: 602-843-4149