Healthcare Provider Details

I. General information

NPI: 1699000802
Provider Name (Legal Business Name): PHOENIX CHILDRENS HOSPITAL MARICOPA MEDICAL CENTER PEDIATRIC RESIDENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

2640 E ANDERSON DR
PHOENIX AZ
85032-2404
US

V. Phone/Fax

Practice location:
  • Phone: 602-546-2923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License NumberR71581
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberR71581
License Number StateAZ

VIII. Authorized Official

Name: DAVID PATRICK GALLOWAY
Title or Position: RESIDENT
Credential: MD
Phone: 602-535-4919