Basic Information
| Provider Information | |||||||||
| NPI: | 1609339514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TARZIA | ||||||||
| FirstName: | BRENDAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | MARICOPA INTEGRATED HEALTH SYSTEM | ||||||||
| Address2: | 2601 E. ROOSEVELT ST. | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85008 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | MARICOPA INTEGRATED HEALTH SYSTEM | ||||||||
| Address2: | 2601 E. ROOSEVELT ST. | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023445411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 100668927 | 05 | CT | MEDICAID |