Healthcare Provider Details

I. General information

NPI: 1972768968
Provider Name (Legal Business Name): PEDIATRIC MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2008
Last Update Date: 07/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BASELINE RD BLDG 3 SUITE 125
MESA AZ
85206-4676
US

IV. Provider business mailing address

4824 E BASELINE RD BLDG 3 SUITE 125
MESA AZ
85206-4676
US

V. Phone/Fax

Practice location:
  • Phone: 480-839-4848
  • Fax: 480-833-8310
Mailing address:
  • Phone: 480-839-4848
  • Fax: 480-833-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12191
License Number StateAZ

VIII. Authorized Official

Name: DR. LOUIS IORIO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 602-228-3986