Provider Demographics
NPI:1578775110
Name:CONCORDIA ONCOLOGY, PC
Entity Type:Organization
Organization Name:CONCORDIA ONCOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLIS
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-614-0556
Mailing Address - Street 1:10250 N 92ND ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4510
Mailing Address - Country:US
Mailing Address - Phone:480-614-0556
Mailing Address - Fax:480-614-9810
Practice Address - Street 1:10250 N 92ND ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4510
Practice Address - Country:US
Practice Address - Phone:480-614-0556
Practice Address - Fax:480-614-9810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ321434174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ170879Medicaid
AZD44492Medicare UPIN
AZMD15515Medicare ID - Type Unspecified