Provider Demographics
NPI:1073970133
Name:MEDIFAST TUCSON COM INCORPORATED
Entity Type:Organization
Organization Name:MEDIFAST TUCSON COM INCORPORATED
Other - Org Name:BARD T. MANNY, MD.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:T
Authorized Official - Last Name:MANNY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-733-2250
Mailing Address - Street 1:PO BOX 14377
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-4377
Mailing Address - Country:US
Mailing Address - Phone:520-733-2250
Mailing Address - Fax:520-733-2270
Practice Address - Street 1:5350 E ERICKSON DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2822
Practice Address - Country:US
Practice Address - Phone:520-733-2250
Practice Address - Fax:520-733-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty