Provider Demographics
NPI:1629439005
Name:GREATER PHOENIX ORTHOPEDICS
Entity Type:Organization
Organization Name:GREATER PHOENIX ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GILLELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-208-7979
Mailing Address - Street 1:20401 N 73RD ST STE 160
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4149
Mailing Address - Country:US
Mailing Address - Phone:800-483-0726
Mailing Address - Fax:800-483-0729
Practice Address - Street 1:20401 N 73RD ST
Practice Address - Street 2:SUITE 155
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4107
Practice Address - Country:US
Practice Address - Phone:800-483-0726
Practice Address - Fax:800-483-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34339207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I37286Medicare UPIN