Basic Information
| Provider Information | |||||||||
| NPI: | 1871567461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RACOWSKY | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32950 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850642950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024331822 | ||||||||
| FaxNumber: | 6022467060 | ||||||||
| Practice Location | |||||||||
| Address1: | 8260 W INDIAN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6328467122 | ||||||||
| FaxNumber: | 6238467027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1229 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 154873 | 05 | AZ | MEDICAID | 67566 | 01 | AZ | MEDICARE PIN # | OTHER |