Provider Demographics
NPI:1770647380
Name:GILBERT ROAD FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:GILBERT ROAD FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-898-9686
Mailing Address - Street 1:643 N GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-6659
Mailing Address - Country:US
Mailing Address - Phone:480-898-9686
Mailing Address - Fax:480-898-1092
Practice Address - Street 1:643 N GILBERT RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-6659
Practice Address - Country:US
Practice Address - Phone:480-898-9686
Practice Address - Fax:480-898-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1788207R00000X
AZ26874207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69781Medicare PIN