Basic Information
| Provider Information | |||||||||
| NPI: | 1578583928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEARNEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | STE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 10494 W THUNDERBIRD BLVD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 35801 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | 35801 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 124466 | 05 | AZ | MEDICAID | 5550830009 | 01 | AZ | MEDICARE NSC AZ NORTH | OTHER | 5550830004 | 01 | AZ | MEDICARE NSC PV | OTHER | 5550830010 | 01 | AZ | MEDICARE NSC GILBERT | OTHER | 5550830003 | 01 | AZ | MEDICARE NSC PEORIA | OTHER | 5550830006 | 01 | AZ | MEDICARE NSC ANTHEM | OTHER | 5550830007 | 01 | AZ | MEDICARE NSC DV | OTHER | 5550830008 | 01 | AZ | MEDICARE NSC SWV | OTHER | 5550830001 | 01 | AZ | MEDICARE NSC SCW | OTHER |