Provider Demographics
NPI:1508180043
Name:PROVIDENCE GENERAL MEDICINE
Entity Type:Organization
Organization Name:PROVIDENCE GENERAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-254-7077
Mailing Address - Street 1:1701 W GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-9701
Mailing Address - Country:US
Mailing Address - Phone:602-246-9090
Mailing Address - Fax:602-246-9867
Practice Address - Street 1:1701 W GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9701
Practice Address - Country:US
Practice Address - Phone:602-246-9090
Practice Address - Fax:602-246-9867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3603261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty