Provider Demographics
NPI:1063446227
Name:ARIZONA EMERGENCY SPECIALIST, PC
Entity Type:Organization
Organization Name:ARIZONA EMERGENCY SPECIALIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLCOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-923-5000
Mailing Address - Street 1:PO BOX 80072
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8072
Mailing Address - Country:US
Mailing Address - Phone:818-340-9988
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:3929 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2112
Practice Address - Country:US
Practice Address - Phone:602-923-5000
Practice Address - Fax:818-587-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0306240OtherBLUE SHIELD
AZ973596Medicaid
AZAZ0306240OtherBLUE SHIELD