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General NPI Number Information
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NPI Number | 1801893425
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Entity Type | Organization
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Legal Business Name | SURPRISE PEDIATRICS
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Dates
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Enumeration Date | 06/29/2005
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Last Update Date | 10/21/2014
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Provider Practice Location Address
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Address Line | 14239 W BELL RD SUITE 112
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City | SURPRISE
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State | AZ
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Zip | 85374-2469
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Country | US
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Telephone | 623-876-9983
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Fax | 623-876-9984
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Provider Business Mailing Address
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Address Line | 14239 W BELL RD SUITE 112
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City | SURPRISE
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State | AZ
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Zip | 85374-2469
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Country | US
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Telephone | 623-876-9983
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Fax | 623-876-9984
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Authorized Official
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Title or Position | CEO
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Name | NICHOLAS MINH PHAM
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Credential | MD
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Telephone | 623-876-9983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | 28681
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License Number State | AZ
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