Healthcare Provider Details

I. General information

NPI: 1366723280
Provider Name (Legal Business Name): SOLSTICE PEDIATRICS AND SPORTS MEDICINE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4731 S WHITE MOUNTAIN RD
SHOW LOW AZ
85901-7818
US

IV. Provider business mailing address

2702 E SYLVIA ST
TUCSON AZ
85716-2181
US

V. Phone/Fax

Practice location:
  • Phone: 203-913-7092
  • Fax:
Mailing address:
  • Phone: 203-913-7092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44940
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number44940
License Number StateAZ

VIII. Authorized Official

Name: MICHAEL JOSEPH PUCHOWICZ
Title or Position: AUTHORIZED MEMBER
Credential: MD
Phone: 203-913-7092