Healthcare Provider Details

I. General information

NPI: 1295028587
Provider Name (Legal Business Name): PHOENIX CHILDREN'S HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 E VAN BUREN ST
PHOENIX AZ
85008-6812
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-933-0945
  • Fax: 602-933-4263
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSH3107
License Number StateAZ

VIII. Authorized Official

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