Basic Information
| Provider Information | |||||||||
| NPI: | 1518945120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THIRTY THIRD AVENUE MEDICAL LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32950 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024331822 | ||||||||
| FaxNumber: | 6022467060 | ||||||||
| Practice Location | |||||||||
| Address1: | 3302 W THOMAS RD | ||||||||
| Address2: | #10 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022332900 | ||||||||
| FaxNumber: | 6022333897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 03/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | BISKUPSKI | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6024331822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OTC2674 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 630708 | 05 | AZ | MEDICAID |