Healthcare Provider Details

I. General information

NPI: 1871788513
Provider Name (Legal Business Name): PHOENIX PEDIATRICS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 07/21/2022
Certification Date: 08/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4434 N 12TH ST
PHOENIX AZ
85014-4507
US

IV. Provider business mailing address

4434 N 12TH ST
PHOENIX AZ
85014-4507
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-5121
  • Fax:
Mailing address:
  • Phone: 602-242-5121
  • Fax: 602-242-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NANCIE ODONNELL
Title or Position: BILLING AND CODING COORDIATOR
Credential:
Phone: 602-242-5121