Provider Demographics
NPI:1619941184
Name:EAST VALLEY NEUROLOGY P C
Entity Type:Organization
Organization Name:EAST VALLEY NEUROLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:480-926-0644
Mailing Address - Street 1:6532 E BRONCO DR
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-3100
Mailing Address - Country:US
Mailing Address - Phone:480-926-0644
Mailing Address - Fax:480-926-0645
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:SUITE #146
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-6675
Practice Address - Country:US
Practice Address - Phone:480-926-0644
Practice Address - Fax:480-926-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16882084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ-27711Medicare ID - Type Unspecified
AZE20698Medicare UPIN