Healthcare Provider Details

I. General information

NPI: 1508998147
Provider Name (Legal Business Name): ARIZONA PEDIATRIC UROLOGY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 E SHEA BLVD D-110
PHOENIX AZ
85028-3070
US

IV. Provider business mailing address

PO BOX 41090
MESA AZ
85274-1090
US

V. Phone/Fax

Practice location:
  • Phone: 480-391-8989
  • Fax:
Mailing address:
  • Phone: 480-391-8989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number30105
License Number StateAZ

VIII. Authorized Official

Name: DR. PHILIP E GLEASON
Title or Position: PEDIATRIC UROLOGIST
Credential: MD
Phone: 480-391-8989