Provider Demographics
NPI:1093050601
Name:MATERNAL FETAL MEDICINE OF ARIZONA LLC
Entity Type:Organization
Organization Name:MATERNAL FETAL MEDICINE OF ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-399-3880
Mailing Address - Street 1:8912 E PINNACLE PEAK RD
Mailing Address - Street 2:STE F9-585
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4852 E BASELINE RD
Practice Address - Street 2:STE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4627
Practice Address - Country:US
Practice Address - Phone:480-467-3545
Practice Address - Fax:480-467-3565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-07
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40444207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty