Healthcare Provider Details

I. General information

NPI: 1336758861
Provider Name (Legal Business Name): PEDIATRICS GPS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5861 N ORACLE RD
TUCSON AZ
85704-3813
US

IV. Provider business mailing address

5861 N ORACLE RD
TUCSON AZ
85704-3813
US

V. Phone/Fax

Practice location:
  • Phone: 520-293-6686
  • Fax:
Mailing address:
  • Phone: 520-293-6686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY MACKNESS
Title or Position: CREDENTIALING LEAD
Credential:
Phone: 520-324-2308