Provider Demographics
NPI:1043434897
Name:KYRENE MEDICAL CENTER PC
Entity Type:Organization
Organization Name:KYRENE MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPONG-TAKYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-598-4145
Mailing Address - Street 1:4545 E CHANDLER BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7643
Mailing Address - Country:US
Mailing Address - Phone:480-598-4145
Mailing Address - Fax:480-598-4346
Practice Address - Street 1:4545 E CHANDLER BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7643
Practice Address - Country:US
Practice Address - Phone:480-598-4145
Practice Address - Fax:480-598-4346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106699Medicare ID - Type UnspecifiedMEDICARE NUMBER