Provider Demographics
NPI:1598782302
Name:LOTUS INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:LOTUS INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-564-0110
Mailing Address - Street 1:18275 N 59TH AVE STE 142
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1253
Mailing Address - Country:US
Mailing Address - Phone:602-564-0110
Mailing Address - Fax:602-564-0111
Practice Address - Street 1:18275 N 59TH AVE STE 142
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1253
Practice Address - Country:US
Practice Address - Phone:602-564-0110
Practice Address - Fax:602-564-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25615207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23302Medicare ID - Type Unspecified
AZG61124Medicare UPIN