Provider Demographics
NPI:1013024777
Name:LIFESCAPE MEDICAL ASSOCIATES, PC
Entity Type:Organization
Organization Name:LIFESCAPE MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-860-5500
Mailing Address - Street 1:8757 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1322
Mailing Address - Country:US
Mailing Address - Phone:480-860-5500
Mailing Address - Fax:480-860-5511
Practice Address - Street 1:8757 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1322
Practice Address - Country:US
Practice Address - Phone:480-860-5500
Practice Address - Fax:480-860-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH56099OtherSTROHMAN
AZI50805Medicare UPIN
AZG16344Medicare UPIN
AZH39665Medicare UPIN
AZH56099OtherSTROHMAN