Provider Demographics
NPI:1699973750
Name:PENDLETON PEDIATRICS PC
Entity type:Organization
Organization Name:PENDLETON PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-385-5055
Mailing Address - Street 1:1445 W CHANDER BLVD
Mailing Address - Street 2:BLDG B
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248
Mailing Address - Country:US
Mailing Address - Phone:480-338-5505
Mailing Address - Fax:480-385-5054
Practice Address - Street 1:1445 W CHANDER BLVD
Practice Address - Street 2:BLDG B
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248
Practice Address - Country:US
Practice Address - Phone:480-338-5505
Practice Address - Fax:480-385-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ389777Medicaid