Basic Information
| Provider Information | |||||||||
| NPI: | 1114698172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MSK CENTER OF MESA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8427 E BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852094381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803576500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8427 E BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852094381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803576500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2021 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLOOM | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4803576500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1083025423 | 01 | AZ | NPI | OTHER | 1962819235 | 01 | NY | NPI | OTHER | 1730480666 | 01 | AZ | NPI | OTHER | 1710185384 | 01 | TN | NPI | OTHER |