MEDICARE: OLD PUEBLO PEDIATRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1376723999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLD PUEBLO PEDIATRICS

Provider Business Mailing Address
First Line	:	7320 N LA CHOLLA BLVD # 154-501
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2309
Country	:	US
Telephone Number	:	520-797-7070
Fax Number	:	520-797-7077

Provider Business Practice Location Address
First Line	:	3043 W INA RD STE 115
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2107
Country	:	US
Telephone Number	:	520-797-7070
Fax Number	:	520-797-7077

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN RAY BEAN
Credential	:	M. D
Telephone Number	:	520-797-7070

Provider Enumeration Date	:	11/12/2007
Last Update Date	:	11/12/2007

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