Healthcare Provider Details

I. General information

NPI: 1679543961
Provider Name (Legal Business Name): PEDIATRICS IN THE PINES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 S WHITE MOUNTAIN ROAD
SHOW LOW AZ
85901
US

IV. Provider business mailing address

3401 S WHITE MOUNTAIN ROAD
SHOW LOW AZ
85901
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-5437
  • Fax: 928-537-5857
Mailing address:
  • Phone: 928-537-5437
  • Fax: 928-537-5857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS D BARELA
Title or Position: EMPLOYEE
Credential: MD
Phone: 928-537-6567