Basic Information
Provider Information | |||||||||
NPI: | 1356584197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCREARY | ||||||||
FirstName: | FELICIA | ||||||||
MiddleName: | MAUREEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BIRCH | ||||||||
OtherFirstName: | FELICIA | ||||||||
OtherMiddleName: | MAUREEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1850 N CENTRAL AVE | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850044527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022628900 | ||||||||
FaxNumber: | 6022628890 | ||||||||
Practice Location | |||||||||
Address1: | 1850 N CENTRAL AVE | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850044527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022628900 | ||||||||
FaxNumber: | 6022628890 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2009 | ||||||||
LastUpdateDate: | 10/31/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 60091444 | WA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 44725 | AZ | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 645912 | 05 | AZ |   | MEDICAID |