Basic Information
Provider Information | |||||||||
NPI: | 1295028587 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHOENIX CHILDREN'S HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHOENIX CHILDREN'S HOSPITAL MEDICAL CREWS VAN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 3333 E VAN BUREN ST | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850086812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029330945 | ||||||||
FaxNumber: | 6029334263 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2011 | ||||||||
LastUpdateDate: | 04/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FAROUGH | ||||||||
AuthorizedOfficialFirstName: | RAHEEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP, MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 6029333548 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHOENIX CHILDREN'S HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | SH3107 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.