Provider Demographics
NPI:1023207131
Name:COMPREHENSIVE BREAST CENTER OF ARIZONA PLC
Entity Type:Organization
Organization Name:COMPREHENSIVE BREAST CENTER OF ARIZONA PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIVAKAMI
Authorized Official - Middle Name:BRENDA
Authorized Official - Last Name:MOORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-545-2610
Mailing Address - Street 1:9179 W THUNDERBIRD RD # 103
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4875
Mailing Address - Country:US
Mailing Address - Phone:480-545-2610
Mailing Address - Fax:480-545-2673
Practice Address - Street 1:9179 W THUNDERBIRD RD # 103
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4875
Practice Address - Country:US
Practice Address - Phone:480-545-2610
Practice Address - Fax:480-545-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105045Medicare PIN