Basic Information
| Provider Information | |||||||||
| NPI: | 1316913262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YANISH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 E CAMELBACK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022649100 | ||||||||
| FaxNumber: | 6022649101 | ||||||||
| Practice Location | |||||||||
| Address1: | 5823 W EUGIE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853041276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028431265 | ||||||||
| FaxNumber: | 6028431297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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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 | 207RG0100X | 17047 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 120390 | 01 | AZ | GROUP MEDICARE NUMBER | OTHER | 271164-05 | 05 | AZ | MEDICAID | 317047 | 01 | AZ | GROUP MEDICAID NUMBER | OTHER | 271164 01 | 05 | AZ | MEDICAID |