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General NPI Number Information
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NPI Number | 1003938283
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Entity Type | Organization
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Legal Business Name | SCOTTSDALE PEDIATRIC CENTER
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 10200 N 92ND ST SUITE 120
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-4534
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Country | US
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Telephone | 480-860-1161
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Fax | 480-860-6561
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Provider Business Mailing Address
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Address Line | 10200 N 92ND ST SUITE 120
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-4534
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Country | US
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Telephone | 480-860-1161
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Fax | 480-860-6561
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Authorized Official
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Title or Position | PHYSICIAN
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Name | RUSSELLE WALLACE
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Credential | M.D.
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Telephone | 480-860-1161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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