Basic Information
| Provider Information | |||||||||
| NPI: | 1639164833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC GROUP SPECIALISTS, LTD. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15650 N BLACK CANYON HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850534064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028660550 | ||||||||
| FaxNumber: | 6025642663 | ||||||||
| Practice Location | |||||||||
| Address1: | 15650 N BLACK CANYON HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850534064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028660550 | ||||||||
| FaxNumber: | 6025642663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERCHOLD | ||||||||
| AuthorizedOfficialFirstName: | JACEK | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6028660550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.