Provider Demographics
NPI:1235305574
Name:PHOENIX INFECTIOUS DISEASES CONSULTANTS LLC
Entity Type:Organization
Organization Name:PHOENIX INFECTIOUS DISEASES CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NDIDIAMAKA
Authorized Official - Middle Name:U
Authorized Official - Last Name:OBIESIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-790-4108
Mailing Address - Street 1:530 E MCDOWELL RD STE 107-609
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1549
Mailing Address - Country:US
Mailing Address - Phone:602-790-4108
Mailing Address - Fax:623-218-9209
Practice Address - Street 1:3330 N 2ND ST STE 401
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2371
Practice Address - Country:US
Practice Address - Phone:602-254-1136
Practice Address - Fax:602-279-1720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30584207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
71505OtherMEDICARE UNSPEC
AZ763062Medicaid
71505OtherMEDICARE UNSPEC