Provider Demographics
NPI:1821269374
Name:MICHAEL D DERSAM MD PC
Entity Type:Organization
Organization Name:MICHAEL D DERSAM MD PC
Other - Org Name:MICHAEL D DERSAM MD PC AN ARIZONA PROFESSIONAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DERSAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-667-6640
Mailing Address - Street 1:2222 E HIGHLAND AVE
Mailing Address - Street 2:SUITE 425
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-667-6640
Mailing Address - Fax:602-522-2677
Practice Address - Street 1:2222 E HIGHLAND AVE
Practice Address - Street 2:SUITE 425
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-667-6640
Practice Address - Fax:602-522-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30263174400000X
AZAZ30263207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG80527Medicare UPIN
AZZ78548Medicare PIN