Basic Information
| Provider Information | |||||||||
| NPI: | 1124296983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFILIATED NEUROLOGISTS LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 N 18TH ST | ||||||||
| Address2: | ST 602 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850063726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022710950 | ||||||||
| FaxNumber: | 6022581386 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 N 18TH ST | ||||||||
| Address2: | ST 602 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850063726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022710950 | ||||||||
| FaxNumber: | 6022581386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2008 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | POWERS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6022710950 | ||||||||
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| 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 | 2084N0400X | 9809 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 253229 | 05 | AZ | MEDICAID |