Provider Demographics
NPI:1649206301
Name:MARYVALE CARDIOLOGY PC
Entity Type:Organization
Organization Name:MARYVALE CARDIOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:623-848-3295
Mailing Address - Street 1:8410 W THOMAS RD
Mailing Address - Street 2:BLDG 2, SUITE 116
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3329
Mailing Address - Country:US
Mailing Address - Phone:623-848-3295
Mailing Address - Fax:623-848-3019
Practice Address - Street 1:8410 W THOMAS RD
Practice Address - Street 2:BLDG 2, SUITE 116
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3329
Practice Address - Country:US
Practice Address - Phone:623-848-3295
Practice Address - Fax:623-848-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ128037OtherPTAN
AZ409313Medicaid
AZZ128037OtherPTAN
AZE45444Medicare UPIN
AZD36761Medicare UPIN
AZI24287Medicare UPIN