Healthcare Provider Details

I. General information

NPI: 1073102976
Provider Name (Legal Business Name): BETHESDA PEDIATRICS OF QUEEN CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S 63RD ST
MESA AZ
85206-1620
US

IV. Provider business mailing address

22707 S ELLSWORTH RD STE H101
QUEEN CREEK AZ
85142-7568
US

V. Phone/Fax

Practice location:
  • Phone: 480-792-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STACIE SELF
Title or Position: BILLING
Credential:
Phone: 480-792-9200