Basic Information
| Provider Information | |||||||||
| NPI: | 1881919777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONCENTRA WORKSITE OF ARIZONA, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AETNA WELNESS WORKS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4645 E COTTON CENTER BLVD | ||||||||
| Address2: | BLDG 1 - F829 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850408874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025861854 | ||||||||
| FaxNumber: | 6024317078 | ||||||||
| Practice Location | |||||||||
| Address1: | 5080 SPECTRUM DR | ||||||||
| Address2: | SUITE 1200W | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723648000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2010 | ||||||||
| LastUpdateDate: | 04/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | FOGARTY | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP / CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9723648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.