Basic Information
| Provider Information | |||||||||
| NPI: | 1770746554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADAN | ||||||||
| FirstName: | REECHA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3411 N 5TH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0267890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Practice Location | |||||||||
| Address1: | 3411 N 5TH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0267890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 06/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P3193 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 55748 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 263996YMHS | 01 | TX | WELLMED NETWORKS INC | OTHER | TXB154750 | 01 | WELLMED MEDICAL GROUP PA | OTHER |