Basic Information
| Provider Information | |||||||||
| NPI: | 1083841704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLISCH | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2009 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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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 | 207W00000X | TP099 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 55265 | AZ | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 35121199 | OH | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0009X | 55265 | AZ | Y |
ID Information
| ID | Type | State | Issuer | Description | 332409 | 05 | AZ | MEDICAID |