Healthcare Provider Details

I. General information

NPI: 1184948416
Provider Name (Legal Business Name): SKYLINE PEDIATRICS PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 11/12/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 N 1ST AVE
TUCSON AZ
85718-5615
US

IV. Provider business mailing address

4930 N 1ST AVE
TUCSON AZ
85718-5615
US

V. Phone/Fax

Practice location:
  • Phone: 520-577-3333
  • Fax: 520-577-4685
Mailing address:
  • Phone: 520-577-3333
  • Fax: 520-577-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40475
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number33544
License Number StateAZ

VIII. Authorized Official

Name: MR. BRICE KOPAS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 520-834-5020