Provider Demographics
NPI:1598872186
Name:PARADISE VALLEY FAMILY MEDICINE, PC
Entity Type:Organization
Organization Name:PARADISE VALLEY FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-494-5118
Mailing Address - Street 1:11209 N. TATUM BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028
Mailing Address - Country:US
Mailing Address - Phone:602-494-5155
Mailing Address - Fax:602-494-5115
Practice Address - Street 1:11209 N TATUM BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3091
Practice Address - Country:US
Practice Address - Phone:602-494-5155
Practice Address - Fax:602-494-5115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-02-11
Deactivation Date:2018-11-05
Deactivation Code:
Reactivation Date:2020-02-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
63710Medicare ID - Type Unspecified