Basic Information
| Provider Information | |||||||||
| NPI: | 1962401513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | EDITH | ||||||||
| MiddleName: | PROCTOR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAILEY-CRAIG | ||||||||
| OtherFirstName: | EDITH | ||||||||
| OtherMiddleName: | PROCTOR (LAETSCH) | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | CHILDREN'S CLINICS | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203245437 | ||||||||
| FaxNumber: | 5203243129 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 N WYATT DR | ||||||||
| Address2: | CHILDREN'S CLINICS | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857126106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203245437 | ||||||||
| FaxNumber: | 5203243129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2005 | ||||||||
| LastUpdateDate: | 01/09/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 19745 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 125246 | 05 | AZ | MEDICAID | AZ0881600 | 01 | AZ | BC/BS | OTHER |