Basic Information
| Provider Information | |||||||||
| NPI: | 1033453733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX CHILDREN'S HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHOENIX CHILDREN'S URGENT CARE CENTERS | ||||||||
| 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: | 6029331000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSBORNE | ||||||||
| AuthorizedOfficialFirstName: | CASEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, PCCN OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6029332645 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHOENIX CHILDREN'S HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | SH3107 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 778399 | 05 | AZ | MEDICAID |