Healthcare Provider Details

I. General information

NPI: 1487814240
Provider Name (Legal Business Name): PHOENIX CHILDREN'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 E SOUTHERN AVE
MESA AZ
85206-2799
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0002
  • Fax: 602-933-6216
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberSH3107
License Number StateAZ

VIII. Authorized Official

Name: RAHEEL FAROUGH
Title or Position: SVP, MANAGED CARE & PAYER STRATEGY
Credential:
Phone: 602-933-3548