Provider Demographics
NPI:1033487442
Name:PHILIP KACZAR MD PC
Entity Type:Organization
Organization Name:PHILIP KACZAR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-252-3967
Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:SUITE #516
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-252-3967
Mailing Address - Fax:602-252-1474
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE #516
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-252-3967
Practice Address - Fax:602-252-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ457516Medicaid
AZ457516Medicaid