Provider Demographics
NPI:1326145608
Name:VERSATILE MEDICINE PLLC
Entity Type:Organization
Organization Name:VERSATILE MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/GENERAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-975-8400
Mailing Address - Street 1:13055 W MCDOWELL RD
Mailing Address - Street 2:SUITE E-106
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6449
Mailing Address - Country:US
Mailing Address - Phone:623-975-8400
Mailing Address - Fax:623-935-2975
Practice Address - Street 1:13055 W MCDOWELL RD
Practice Address - Street 2:SUITE E-106
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6449
Practice Address - Country:US
Practice Address - Phone:623-975-8400
Practice Address - Fax:623-935-2975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ26993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0761300OtherBLUE CROSS BLUE SHIELD
AZAZ0765500OtherBLUE CROSS BLUE SHIELD
AZ517675Medicaid
AZ486581001Medicaid
AZAZ0761300OtherBLUE CROSS BLUE SHIELD
AZ517675Medicaid
AZ486581001Medicaid
AZH24006Medicare UPIN