Provider Demographics
NPI:1083700876
Name:GRAYHAWK FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:GRAYHAWK FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-473-7003
Mailing Address - Street 1:21803 N SCOTTSDALE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-7446
Mailing Address - Country:US
Mailing Address - Phone:480-473-7003
Mailing Address - Fax:480-473-4499
Practice Address - Street 1:21803 N SCOTTSDALE RD STE 200
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-7446
Practice Address - Country:US
Practice Address - Phone:480-473-7003
Practice Address - Fax:480-473-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207Q00000X
AZ22985208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529935Medicaid
AZ529935Medicaid
AZZ77075Medicare UPIN
AZ77075Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER