Provider Demographics
NPI:1629616727
Name:IMD PHYSICIANS ARIZONA PLLC
Entity Type:Organization
Organization Name:IMD PHYSICIANS ARIZONA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:831-818-9833
Mailing Address - Street 1:4325 E GLACIER PLACE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-5653
Mailing Address - Country:US
Mailing Address - Phone:602-318-7878
Mailing Address - Fax:
Practice Address - Street 1:7250 N 16TH ST STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5214
Practice Address - Country:US
Practice Address - Phone:602-714-2815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty