Provider Demographics
NPI:1417119108
Name:WOMEN'S MEDICAL GROUP OF TEMPE
Entity Type:Organization
Organization Name:WOMEN'S MEDICAL GROUP OF TEMPE
Other - Org Name:EAST VALLEY WOMEN'S MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR/ BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:SEVILLANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-632-2004
Mailing Address - Street 1:4915 E BASELINE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2966
Mailing Address - Country:US
Mailing Address - Phone:480-632-2004
Mailing Address - Fax:
Practice Address - Street 1:4915 E BASELINE RD STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2966
Practice Address - Country:US
Practice Address - Phone:480-632-2004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33219174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ83790OtherMEDICARE PTAN
AZ83790OtherMEDICARE PTAN