Basic Information
| Provider Information | |||||||||
| NPI: | 1417327107 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALOGICS SPECIALTY PHYSICIANS OF ARIZONA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 BELFORT RD STE 130 | ||||||||
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| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044463451 | ||||||||
| FaxNumber: | 9044463032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MILL AVE | ||||||||
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| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852816699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803335152 | ||||||||
| FaxNumber: | 4803335163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2015 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BASSIN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8556895105 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 235369 | 05 | AZ | MEDICAID |