Basic Information
| Provider Information | |||||||||
| NPI: | 1629076518 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTTSDALE PEDIATRICS AND PEDIATRIC NEPHROLOGY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AGAVE PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7010 E. CHAUNCEY LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850543117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805855200 | ||||||||
| FaxNumber: | 4805855233 | ||||||||
| Practice Location | |||||||||
| Address1: | 7010 E. CHAUNCEY LN | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850543117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805855200 | ||||||||
| FaxNumber: | 4805855233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | AGARWAL | ||||||||
| AuthorizedOfficialFirstName: | RAJEEV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4805855200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33323 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0210X | 33323 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.