Healthcare Provider Details

I. General information

NPI: 1063727766
Provider Name (Legal Business Name): BETHESDA PEDIATRICS OF QUEEN CREEK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22707 S ELLSWORTH RD STE H101
QUEEN CREEK AZ
85142-7568
US

IV. Provider business mailing address

22707 S ELLSWORTH RD STE H101
QUEEN CREEK AZ
85142-7568
US

V. Phone/Fax

Practice location:
  • Phone: 480-792-9200
  • Fax: 480-792-9206
Mailing address:
  • Phone: 480-792-9200
  • Fax: 480-792-9206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43623
License Number StateAZ

VIII. Authorized Official

Name: ELMER PORTILLO
Title or Position: CFO
Credential:
Phone: 602-531-0302