Basic Information
| Provider Information | |||||||||
| NPI: | 1871898288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARIZONA FOOT AND ANKLE MEDICINE AND SURGERY, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13385 | ||||||||
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| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852673385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806099300 | ||||||||
| FaxNumber: | 4806099350 | ||||||||
| Practice Location | |||||||||
| Address1: | 1347 N GREENFIELD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852054072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806998762 | ||||||||
| FaxNumber: | 4806998350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | SANDALL | ||||||||
| AuthorizedOfficialFirstName: | BLAIR | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4806998762 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 0704 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 531450 | 05 | AZ | MEDICAID |