Basic Information
| Provider Information | |||||||||
| NPI: | 1366081705 | ||||||||
| 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: | 6024705000 | ||||||||
| FaxNumber: | 6024705064 | ||||||||
| Practice Location | |||||||||
| Address1: | 3624 W ANTHEM WAY STE C116 | ||||||||
| Address2: | |||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850860457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234345748 | ||||||||
| FaxNumber: | 6235518882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2020 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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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: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 475747 | 05 | AZ | MEDICAID |