Provider Demographics
NPI:1225023377
Name:GERIATRIC SPECIALTIES OF ARIZONA PC
Entity Type:Organization
Organization Name:GERIATRIC SPECIALTIES OF ARIZONA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-864-8800
Mailing Address - Street 1:6838 N 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1056
Mailing Address - Country:US
Mailing Address - Phone:602-864-8800
Mailing Address - Fax:602-864-1448
Practice Address - Street 1:6838 N 23RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1056
Practice Address - Country:US
Practice Address - Phone:602-864-8800
Practice Address - Fax:602-864-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19651207R00000X
AZ16113207R00000X
AZ30953207R00000X
AZ31629207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79489Medicare ID - Type UnspecifiedLEVY MD
AZ79487Medicare PIN
AZ82380Medicare ID - Type UnspecifiedCOMBS MD
AZD15567Medicare UPIN
AZE55258Medicare UPIN
AZ82378Medicare ID - Type UnspecifiedPRETLOW MD