Provider Demographics
NPI:1073647251
Name:ELIZABETH E WACK MD PC
Entity Type:Organization
Organization Name:ELIZABETH E WACK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:WACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-575-6944
Mailing Address - Street 1:2055 W HOSPITAL DR
Mailing Address - Street 2:SUITE 175
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704
Mailing Address - Country:US
Mailing Address - Phone:520-575-6944
Mailing Address - Fax:520-575-1115
Practice Address - Street 1:2055 W HOSPITAL DR
Practice Address - Street 2:SUITE 175
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704
Practice Address - Country:US
Practice Address - Phone:520-575-6944
Practice Address - Fax:520-575-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14736174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ266446Medicaid
AZ266446Medicaid