Provider Demographics
NPI:1851469803
Name:ARIZONA GRAND MEDICAL
Entity Type:Organization
Organization Name:ARIZONA GRAND MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIANA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GAIDICI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-200-8988
Mailing Address - Street 1:1715 W NORTHERN AVE
Mailing Address - Street 2:108
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-5472
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:1715 W NORTHERN AVE
Practice Address - Street 2:108
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5472
Practice Address - Country:US
Practice Address - Phone:602-395-0718
Practice Address - Fax:602-277-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31367207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty