Healthcare Provider Details

I. General information

NPI: 1366605529
Provider Name (Legal Business Name): MARYVALE PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N. 51ST AVENUE SUITE #4
PHOENIX AZ
85031
US

IV. Provider business mailing address

4700 N. 51ST AVENUE SUITE #4
PHOENIX AZ
85031
US

V. Phone/Fax

Practice location:
  • Phone: 623-846-7575
  • Fax: 623-846-3778
Mailing address:
  • Phone: 623-846-7575
  • Fax: 623-846-3778

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. HARRY L BROOME JR.
Title or Position: OWNER
Credential: M.D.
Phone: 623-846-7575