Basic Information
Provider Information | |||||||||
NPI: | 1376851360 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ATIA | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KAMEL | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3020 E CAMELBACK RD | ||||||||
Address2: | SUITE 301 | ||||||||
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: | 09/23/2010 | ||||||||
LastUpdateDate: | 02/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 45749 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 719963 | 05 | AZ |   | MEDICAID |