Provider Demographics
NPI:1588112080
Name:PHOENIX PEDIATRIC ALLIANCE, PLLC
Entity type:Organization
Organization Name:PHOENIX PEDIATRIC ALLIANCE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MANAF
Authorized Official - Middle Name:GHASSAN
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-767-1888
Mailing Address - Street 1:150 PINE FOREST DR # 702
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-5302
Mailing Address - Country:US
Mailing Address - Phone:713-955-2343
Mailing Address - Fax:
Practice Address - Street 1:150 PINE FOREST DR # 702
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-5302
Practice Address - Country:US
Practice Address - Phone:713-955-2343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2395208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty