Basic Information
| Provider Information | |||||||||
| NPI: | 1124549043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL B BAYLESS AND ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYLESS HEALTHCARE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6026827455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 S DOBSON RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852026457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAYLESS | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022307373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0800X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207Q00000X | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AZ | MEDICAID |