Provider Demographics
NPI:1942646369
Name:FOOTHILLS INTERNAL MEDICINE, PLLC
Entity Type:Organization
Organization Name:FOOTHILLS INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:RISKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-496-0000
Mailing Address - Street 1:600 S DOBSON RD
Mailing Address - Street 2:SUITE D27
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5678
Mailing Address - Country:US
Mailing Address - Phone:480-496-0000
Mailing Address - Fax:480-496-7133
Practice Address - Street 1:600 S DOBSON RD
Practice Address - Street 2:SUITE D27
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5678
Practice Address - Country:US
Practice Address - Phone:480-496-0000
Practice Address - Fax:480-496-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF58892Medicare UPIN
AZZ113363Medicare PIN