Basic Information
| Provider Information | |||||||||
| NPI: | 1508057332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL PROFESSIONAL ASSOCIATES OF ARIZONA | ||||||||
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| OtherOrganizationName: | MEDPRO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2601 E ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850084973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023445098 | ||||||||
| FaxNumber: | 6023441488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | CORDEIRO | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6024705043 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDICAL PROFESSIONAL ASSOCIATES OF ARIZONA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207RI0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 69317 | 01 | AZ | MEDICARE ID GROUP # | OTHER |