Basic Information
| Provider Information | |||||||||
| NPI: | 1851469803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA GRAND MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 W NORTHERN AVE | ||||||||
| Address2: | 108 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850215472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 W NORTHERN AVE | ||||||||
| Address2: | 108 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850215472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GAIDICI | ||||||||
| AuthorizedOfficialFirstName: | ADRIANA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6022008988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 31367 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.