Basic Information
| Provider Information | |||||||||
| NPI: | 1740601962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CALGARY MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4540 E BASELINE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
| FaxNumber: | 4802375682 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E BASELINE RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
| FaxNumber: | 4802375682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2013 | ||||||||
| LastUpdateDate: | 12/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | BUCKNER | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6028895833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.