Provider Demographics
NPI:1225435662
Name:MEDEXAZ LLC
Entity Type:Organization
Organization Name:MEDEXAZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MITREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-284-8265
Mailing Address - Street 1:32 SPUR CIR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5461
Mailing Address - Country:US
Mailing Address - Phone:602-284-8265
Mailing Address - Fax:
Practice Address - Street 1:32 SPUR CIR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5461
Practice Address - Country:US
Practice Address - Phone:602-284-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1023087293207Q00000X, 208D00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty