Basic Information
| Provider Information | |||||||||
| NPI: | 1366605529 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYVALE PEDIATRIC CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MVP KIDS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 N. 51ST AVENUE | ||||||||
| Address2: | SUITE #4 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238467575 | ||||||||
| FaxNumber: | 6238463778 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 N. 51ST AVENUE | ||||||||
| Address2: | SUITE #4 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238467575 | ||||||||
| FaxNumber: | 6238463778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROOME | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6238467575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.