Basic Information
Provider Information | |||||||||
NPI: | 1447514450 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHORTRIDGE | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850182327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029331814 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1220 S HIGLEY RD STE 106 | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 85206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029333937 | ||||||||
FaxNumber: | 6029332409 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2012 | ||||||||
LastUpdateDate: | 06/01/2018 | ||||||||
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 | 207R00000X | R73592 | AZ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207W00000X | 39452 | SC | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207W00000X | 54569 | AZ | N |   | Allopathic & Osteopathic Physicians | Ophthalmology |   | 207WX0110X | 54569 | AZ | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | R73592 | 01 | AZ | PERMIT | OTHER |