Provider Demographics
NPI:1366723280
Name:SOLSTICE PEDIATRICS AND SPORTS MEDICINE, PLC
Entity type:Organization
Organization Name:SOLSTICE PEDIATRICS AND SPORTS MEDICINE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PUCHOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-913-7092
Mailing Address - Street 1:2702 E SYLVIA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2181
Mailing Address - Country:US
Mailing Address - Phone:203-913-7092
Mailing Address - Fax:
Practice Address - Street 1:4731 S WHITE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7818
Practice Address - Country:US
Practice Address - Phone:203-913-7092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ449402080S0010X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty