Provider Demographics
NPI:1407804115
Name:RICHARD LEE AVERITTE JR PLLC
Entity Type:Organization
Organization Name:RICHARD LEE AVERITTE JR PLLC
Other - Org Name:AFFILIATED DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:AVERITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-556-0446
Mailing Address - Street 1:20401 N 73RD ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4153
Mailing Address - Country:US
Mailing Address - Phone:480-556-0446
Mailing Address - Fax:480-556-0447
Practice Address - Street 1:20401 N 73RD ST
Practice Address - Street 2:SUITE 230
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4153
Practice Address - Country:US
Practice Address - Phone:480-556-0446
Practice Address - Fax:480-556-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30247207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69745Medicare PIN