Healthcare Provider Details

I. General information

NPI: 1215150131
Provider Name (Legal Business Name): WHITE MOUNTAIN PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 W WHITE MOUNTAIN BLVD SUITE B
LAKESIDE AZ
85929-7002
US

IV. Provider business mailing address

PO BOX 2942
PINETOP AZ
85935-2942
US

V. Phone/Fax

Practice location:
  • Phone: 928-367-1300
  • Fax: 928-367-1330
Mailing address:
  • Phone: 928-367-1300
  • Fax: 928-367-1330

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. EDITH BAILEY
Title or Position: PRESIDENT
Credential: MD
Phone: 928-367-1300