Provider Demographics
NPI:1144206541
Name:HOMEWOOD FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:HOMEWOOD FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:HOMEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-558-4700
Mailing Address - Street 1:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-1927
Mailing Address - Country:US
Mailing Address - Phone:480-558-4700
Mailing Address - Fax:480-558-1936
Practice Address - Street 1:4540 E BASELINE RD
Practice Address - Street 2:#113
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4613
Practice Address - Country:US
Practice Address - Phone:480-558-4700
Practice Address - Fax:480-558-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ423997Medicaid
AZ423997Medicaid