Basic Information
| Provider Information | |||||||||
| NPI: | 1124667555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DISTRICT MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 E THOMAS RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850168034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705519 | ||||||||
| FaxNumber: | 6024705064 | ||||||||
| Practice Location | |||||||||
| Address1: | 15182 N 75TH AVE STE 180 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234873334 | ||||||||
| FaxNumber: | 6234873656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | CORDEIRO | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6024705519 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DISTRICT MEDICAL GROUP, INC | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 475747 | 05 | AZ | MEDICAID |