MEDICARE: APACHE JUNCTION 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	208000000X	Pediatrics Physician	34596	AZ
2	208000000X	Pediatrics Physician	27900	AZ
3	208000000X	Pediatrics Physician	34587	AZ
4	208000000X	Pediatrics Physician	AP0241	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0763370	OTHER	AZ	JB BC ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	AZ0427690	OTHER	AZ	RL BC ID
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588866453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APACHE JUNCTION PEDIATRICS

Provider Business Mailing Address
First Line	:	1075 S IDAHO RD
Second Line	:	SUITE 206
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85219-6496
Country	:	US
Telephone Number	:	480-889-1234
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 S IDAHO RD
Second Line	:	SUITE 206
City	:	APACHE JUNCTION
State	:	AZ
Zip	:	85219-6496
Country	:	US
Telephone Number	:	480-889-1234
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED PEDIATRIC NURSE PRACTIONE
Name	:	MRS. JANET GRADLE
Credential	:	CPNP
Telephone Number	:	480-889-1234

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	08/22/2020

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Directions to “APACHE JUNCTION PEDIATRICS ” Practice Location

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