Basic Information
| Provider Information | |||||||||
| NPI: | 1528305281 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMF GASTROENTEROGY, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GASTROENTEROLOGY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2902 E GARY WAY | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850427107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023097716 | ||||||||
| FaxNumber: | 6022791720 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 N 24TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022546101 | ||||||||
| FaxNumber: | 6022791720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | MUMTAZ | ||||||||
| AuthorizedOfficialFirstName: | RUSHDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6023097716 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 28980 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 550899 | 05 | AZ | MEDICAID |