Provider Demographics
NPI:1740758515
Name:GHENTMD
Entity Type:Organization
Organization Name:GHENTMD
Other - Org Name:GHENTMD INTEGRATIVE HEALTH AND WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:ASUELIMEN
Authorized Official - Last Name:AGHENTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-935-8855
Mailing Address - Street 1:1434 W ELLIOT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5157
Mailing Address - Country:US
Mailing Address - Phone:480-935-8855
Mailing Address - Fax:855-450-1054
Practice Address - Street 1:1434 W ELLIOT RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5157
Practice Address - Country:US
Practice Address - Phone:651-246-7242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-09
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ550726Medicaid