Basic Information
| Provider Information | |||||||||
| NPI: | 1487814240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX CHILDREN'S MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331815 | ||||||||
| FaxNumber: | 6029331820 | ||||||||
| Practice Location | |||||||||
| Address1: | 5131 E SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852062799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029330002 | ||||||||
| FaxNumber: | 6029336216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2008 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FAROUGH | ||||||||
| AuthorizedOfficialFirstName: | RAHEEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 6029333548 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHOENIX CHILDREN'S HOSPITAL, INC. | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | SH3107 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 876253 | 05 | AZ | MEDICAID |