Provider Demographics
NPI:1215012646
Name:NEW IMAGE FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:NEW IMAGE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-705-0480
Mailing Address - Street 1:13838 S 46TH PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7800
Mailing Address - Country:US
Mailing Address - Phone:480-705-0480
Mailing Address - Fax:480-705-0481
Practice Address - Street 1:13838 S 46TH PL
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7800
Practice Address - Country:US
Practice Address - Phone:480-705-0480
Practice Address - Fax:480-705-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherEIN
AZZ113148Medicare PIN
AZG10229Medicare UPIN