Provider Demographics
NPI:1194212977
Name:VITALITY INTERNAL MEDICINE - AVONDALE PLLC
Entity Type:Organization
Organization Name:VITALITY INTERNAL MEDICINE - AVONDALE PLLC
Other - Org Name:MEN'S VITALITY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:602-791-9112
Mailing Address - Street 1:111 E DUNLAP AVE STE 1-193
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-7812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10320 W MCDOWELL RD STE E5015
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4869
Practice Address - Country:US
Practice Address - Phone:602-791-9112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ37616OtherMEDICAL LICENSE
AZFE0530065OtherDEA