MEDICARE: PROVIDENCE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962673772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE PEDIATRICS

Provider Business Mailing Address
First Line	:	9100 N CENTRAL AVE
Second Line	:	SUITE E
City	:	PHOENIX
State	:	AZ
Zip	:	85020-2430
Country	:	US
Telephone Number	:	602-997-9898
Fax Number	:	602-997-9901

Provider Business Practice Location Address
First Line	:	9100 N CENTRAL AVE
Second Line	:	SUITE E
City	:	PHOENIX
State	:	AZ
Zip	:	85020-2430
Country	:	US
Telephone Number	:	602-997-9898
Fax Number	:	602-997-9901

Authorized Official
Title or Position	:	BILLING
Name	:	LOURDES RODRIGUEZ
Credential	:
Telephone Number	:	602-254-7077

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	03/19/2008

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Directions to “PROVIDENCE PEDIATRICS ” Practice Location

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