Basic Information
| Provider Information | |||||||||
| NPI: | 1598872186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARADISE VALLEY FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11209 N. TATUM BLVD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024945155 | ||||||||
| FaxNumber: | 6024945115 | ||||||||
| Practice Location | |||||||||
| Address1: | 11209 N TATUM BLVD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850283091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024945155 | ||||||||
| FaxNumber: | 6024945115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/05/2018 | ||||||||
| NPIReactivationDate: | 02/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6024945118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.