Provider Demographics
NPI:1093170011
Name:CENTER FOR TRANSITIONAL CARE MEDICINE, PLLC
Entity Type:Organization
Organization Name:CENTER FOR TRANSITIONAL CARE MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAST
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:602-513-6598
Mailing Address - Street 1:233 E SOUTHERN AVE
Mailing Address - Street 2:#27776
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5189
Mailing Address - Country:US
Mailing Address - Phone:480-755-2210
Mailing Address - Fax:480-755-2364
Practice Address - Street 1:2501 E SOUTHERN AVE
Practice Address - Street 2:STE 1
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7669
Practice Address - Country:US
Practice Address - Phone:480-755-2210
Practice Address - Fax:480-755-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33212207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ913550Medicaid