1265554612 NPI number — THE PEDIATRIC ENDOCRINE DIABETES CLINIC PC

Table of content: (NPI 1265554612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265554612 NPI number — THE PEDIATRIC ENDOCRINE DIABETES CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PEDIATRIC ENDOCRINE DIABETES CLINIC PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265554612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 W THOMAS RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85013-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-692-7926
Provider Business Mailing Address Fax Number:
602-266-9660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 W THOMAS RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-692-7926
Provider Business Practice Location Address Fax Number:
602-266-9660
Provider Enumeration Date:
04/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KABBANI
Authorized Official First Name:
MAHMOUD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PEDIATRIC ENDOCRINE
Authorized Official Telephone Number:
602-692-7926

Provider Taxonomy Codes

  • Taxonomy code: 2080P0205X , with the licence number:  30355 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1235191727 . This is a "INDIVIUAL NPI" identifier . This identifiers is of the category "OTHER".




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