Basic Information
| Provider Information | |||||||||
| NPI: | 1275764854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERGES | ||||||||
| FirstName: | AMIR | ||||||||
| MiddleName: | EZZAT | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2149 E WARNER RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852843494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 WILLOW CREEK RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806106100 | ||||||||
| FaxNumber: | 4806106189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 006747 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 038696 | 05 | AZ | MEDICAID |