Provider Demographics
NPI:1902888027
Name:GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC
Entity Type:Organization
Organization Name:GOOD NIGHT PEDIATRICS SOUTH MOUNTAIN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-643-9233
Mailing Address - Street 1:10320 W MCDOWELL RD
Mailing Address - Street 2:#L1238
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-4863
Mailing Address - Country:US
Mailing Address - Phone:623-643-9233
Mailing Address - Fax:623-643-9234
Practice Address - Street 1:325 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6510
Practice Address - Country:US
Practice Address - Phone:602-824-4228
Practice Address - Fax:602-824-4259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ961004Medicaid