Basic Information
| Provider Information | |||||||||
| NPI: | 1588613707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3003 N CENTRAL AVE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233344 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 E BROADWAY RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852821614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 4809271092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12048 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4409 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04YP04767NH02 | 01 | NH | NH BLUE CROSS BLUE SHIELD | OTHER | 1009800 | 05 | VT | MEDICAID | RE7231 | 01 | NE | NHIC | OTHER | 8920269 | 01 | NH | CIGNA | OTHER | AA3099 | 01 | HARVARD PILGRIM | OTHER | 00059455 | 01 | VT | VT BLUE CROSS BLUE SHIELD | OTHER | 8000595 | 01 | VT | LADIES FIRST | OTHER | 3076472 | 05 | NH | MEDICAID |