Basic Information
| Provider Information | |||||||||
| NPI: | 1205273406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMERGENCY PROFESSIONAL SERVICES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 N 12TH ST | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028394144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2050 W SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | APACHE JUNCTION | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851207305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802373200 | ||||||||
| FaxNumber: | 6028394144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | KONDAS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9732511132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 299839 | 01 | AZ | AHCCCS | OTHER |