Provider Demographics
NPI:1659402998
Name:EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC
Entity Type:Organization
Organization Name:EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC
Other - Org Name:TUTANKHAMEN PAPPOE MD PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TUTANKHAMEN
Authorized Official - Middle Name:ALLOTEY
Authorized Official - Last Name:PAPPOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-807-6500
Mailing Address - Street 1:4858 E BASELINE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4638
Mailing Address - Country:US
Mailing Address - Phone:480-807-6500
Mailing Address - Fax:866-835-7591
Practice Address - Street 1:4858 E BASELINE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4638
Practice Address - Country:US
Practice Address - Phone:480-807-6500
Practice Address - Fax:866-835-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ330842081P2900X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ873671Medicaid
AZI17731Medicare UPIN
AZZ114653Medicare PIN