Basic Information
| Provider Information | |||||||||
| NPI: | 1659326585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARONDELET MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N. FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727790 | ||||||||
| FaxNumber: | 5208727929 | ||||||||
| Practice Location | |||||||||
| Address1: | 2202 N. FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727790 | ||||||||
| FaxNumber: | 5208727929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | CASTELLANO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT, CHIEF STR | ||||||||
| AuthorizedOfficialTelephone: | 5208727638 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 213ES0131X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 204D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 174400000X | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 653298 | 05 | AZ | MEDICAID |