Basic Information
| Provider Information | |||||||||
| NPI: | 1962735449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIEBORZ PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6722 N 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850131008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022518714 | ||||||||
| FaxNumber: | 6022518899 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 S LINDSAY RD STE 123 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852972100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808219339 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2009 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | KIEBORZ | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4808219555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3836 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 461660 | 05 | AZ | MEDICAID |