Basic Information
| Provider Information | |||||||||
| NPI: | 1003955832 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA FAMILY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2127 E BASELINE RD | ||||||||
| Address2: | 104 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852831537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808977070 | ||||||||
| FaxNumber: | 4808972597 | ||||||||
| Practice Location | |||||||||
| Address1: | 2127 E BASELINE RD | ||||||||
| Address2: | 104 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852831537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808977070 | ||||||||
| FaxNumber: | 4808972597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELLISON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4808977070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD12426 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 214510 | 05 | AZ | MEDICAID | 1669567434 | 01 | NPI | OTHER | AZ0006680 | 01 | BLUE CROSS BLUE SHIELD | OTHER |