Basic Information
| Provider Information | |||||||||
| NPI: | 1316961022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OBSTETRIX MEDICAL GROUP OF ARIZONA, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 N 24TH ST | ||||||||
| Address2: | STE. 150 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022564628 | ||||||||
| FaxNumber: | 8558514319 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 E GRANT RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207958188 | ||||||||
| FaxNumber: | 5203250809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 03/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | MEREDITH | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6022564628 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 367A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 207VM0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 434647 | 05 | AZ | MEDICAID |