Provider Demographics
NPI:1164693974
Name:PROVIDENCE GENERAL MEDICINE, PC
Entity Type:Organization
Organization Name:PROVIDENCE GENERAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SICALO OBORSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-254-7077
Mailing Address - Street 1:9220 N. CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2416
Mailing Address - Country:US
Mailing Address - Phone:602-254-7077
Mailing Address - Fax:602-254-7078
Practice Address - Street 1:9220 N. CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2416
Practice Address - Country:US
Practice Address - Phone:602-254-7077
Practice Address - Fax:602-254-7078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH96910Medicare UPIN
AZZ76844Medicare PIN