Provider Demographics
NPI:1245423789
Name:FAMILY PRACTICE CLINIC LTD
Entity Type:Organization
Organization Name:FAMILY PRACTICE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-278-4930
Mailing Address - Street 1:3306 W ROOSEVELT ST
Mailing Address - Street 2:STE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-3404
Mailing Address - Country:US
Mailing Address - Phone:602-278-4930
Mailing Address - Fax:
Practice Address - Street 1:3306 W ROOSEVELT ST
Practice Address - Street 2:STE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-3404
Practice Address - Country:US
Practice Address - Phone:602-278-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-18
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ261131Medicaid
D47302Medicare UPIN