Provider Demographics
NPI:1518169093
Name:SCOTTSDALE PEAKS FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:SCOTTSDALE PEAKS FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-314-5555
Mailing Address - Street 1:30790 N 77TH WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85266-2787
Mailing Address - Country:US
Mailing Address - Phone:480-657-0357
Mailing Address - Fax:480-314-5556
Practice Address - Street 1:8070 E MORGAN TRL STE 202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1229
Practice Address - Country:US
Practice Address - Phone:480-314-5555
Practice Address - Fax:480-314-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ72613Medicare PIN