Healthcare Provider Details

I. General information

NPI: 1629325378
Provider Name (Legal Business Name): ACTIVE KIDS PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 S 48TH ST SUITE 110
PHOENIX AZ
85044-9142
US

IV. Provider business mailing address

15215 S 48TH ST SUITE 110
PHOENIX AZ
85044-9142
US

V. Phone/Fax

Practice location:
  • Phone: 480-783-8960
  • Fax: 480-783-8967
Mailing address:
  • Phone: 480-783-8960
  • Fax: 480-783-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA32674
License Number StateAZ

VIII. Authorized Official

Name: DR. JUDITH ROSCH BARNES CLARK
Title or Position: PEDIATRICIAN, CO-OWNER
Credential: M.D.
Phone: 480-783-8960