Provider Demographics
NPI:1437482544
Name:DISTRICT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:DISTRICT MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDEIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-470-5519
Mailing Address - Street 1:2929 E THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8034
Mailing Address - Country:US
Mailing Address - Phone:602-470-5000
Mailing Address - Fax:
Practice Address - Street 1:570 W BROWN RD
Practice Address - Street 2:ADMINISTRATION
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3227
Practice Address - Country:US
Practice Address - Phone:480-344-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DISTRICT MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-09
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ475747Medicaid