Basic Information
| Provider Information | |||||||||
| NPI: | 1861449357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY PEDIATRICS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 S DOBSON RD | ||||||||
| Address2: | B218 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809636668 | ||||||||
| FaxNumber: | 4809636669 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 S DOBSON RD | ||||||||
| Address2: | B218 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852245667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809636668 | ||||||||
| FaxNumber: | 4809636669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 02/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHANDRASEKHAR | ||||||||
| AuthorizedOfficialFirstName: | SUDHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4809636668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 649494 | 05 | AZ | MEDICAID |