Basic Information
| Provider Information | |||||||||
| NPI: | 1023475506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX CHILDREN'S HOSPITAL | ||||||||
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| OtherOrganizationName: | PHOENIX CHILDREN'S CARDIOLOGY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD | ||||||||
| Address2: | STE 250 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331815 | ||||||||
| FaxNumber: | 6029331820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029333366 | ||||||||
| FaxNumber: | 6029334166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOFFMAN | ||||||||
| AuthorizedOfficialFirstName: | ETHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 6029331801 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHOENIX CHILDREN'S HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | SH3107 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
No ID Information.