Basic Information
| Provider Information | |||||||||
| NPI: | 1164919056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST VALLEY INFECTIOUS DISEASES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20610 | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852770610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4802967665 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E FLORENCE BLVD | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851225303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204266300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | MARILYNN | ||||||||
| AuthorizedOfficialMiddleName: | JEANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDEENTIALER | ||||||||
| AuthorizedOfficialTelephone: | 4802967642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 48645 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.