Healthcare Provider Details

I. General information

NPI: 1639164833
Provider Name (Legal Business Name): PEDIATRIC GROUP SPECIALISTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 N BLACK CANYON HWY SUITE 100
PHOENIX AZ
85053-4064
US

IV. Provider business mailing address

15650 N BLACK CANYON HWY SUITE 100
PHOENIX AZ
85053-4064
US

V. Phone/Fax

Practice location:
  • Phone: 602-866-0550
  • Fax: 602-993-5788
Mailing address:
  • Phone: 602-866-0550
  • Fax: 602-564-2663

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. DAVID A. KLEINER
Title or Position: CEO
Credential: MD
Phone: 602-866-0550