Basic Information
| Provider Information | |||||||||
| NPI: | 1124541594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERALD T KITCHENS II MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023087888 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 7878 N 16TH ST STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850204478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023087888 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HAMELIN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6023087817 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 30278 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 692790 | 05 | AZ | MEDICAID |