Basic Information
| Provider Information | |||||||||
| NPI: | 1538723531 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN AND PALLIATIVE ASSOCIATES OF ARIZONA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 20610 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852770610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4802967647 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 W BETHANY HOME RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850152443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802967647 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2019 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4808489360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 550618 | 05 | AZ | MEDICAID |