Provider Demographics
NPI:1124232848
Name:ERIC O SHREDER DO PLLC
Entity Type:Organization
Organization Name:ERIC O SHREDER DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:OTTO
Authorized Official - Last Name:SHREDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-926-8000
Mailing Address - Street 1:4838 E BASELINE RD
Mailing Address - Street 2:#103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-926-8000
Mailing Address - Fax:480-926-3445
Practice Address - Street 1:4838 E BASELINE RD
Practice Address - Street 2:#103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4671
Practice Address - Country:US
Practice Address - Phone:480-926-8000
Practice Address - Fax:480-926-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ104969Medicare ID - Type UnspecifiedMEDICARE GROUP