Healthcare Provider Details

I. General information

NPI: 1902888027
Provider Name (Legal Business Name): GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E BASELINE RD
PHOENIX AZ
85042-6510
US

IV. Provider business mailing address

10320 W MCDOWELL RD #L1238
AVONDALE AZ
85323-4863
US

V. Phone/Fax

Practice location:
  • Phone: 602-824-4228
  • Fax: 602-824-4259
Mailing address:
  • Phone: 623-643-9233
  • Fax: 623-643-9234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHY SHICK
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 623-643-9233