Provider Demographics
NPI:1124243688
Name:PONDEROSA PEDIATRICSS PLC
Entity type:Organization
Organization Name:PONDEROSA PEDIATRICSS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARGUESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-443-1111
Mailing Address - Street 1:2120 CENTERPOINTE WEST DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-443-1111
Mailing Address - Fax:928-443-5554
Practice Address - Street 1:2120 CENTERPOINTE WEST DRIVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-443-1111
Practice Address - Fax:928-443-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1912976879OtherINDIVIDUAL NPI
AZ1144299090OtherINDIVIDUAL NPI
AZ1144299678OtherINDIVIDUAL NPI
AZ1336118926OtherINDIVIDUAL NPI
AZ1629047097OtherINDIVIDUAL NPI
AZ1881653558OtherINDIVIDUAL NPI
AZ1326169657OtherINDIVIDUAL NPI