Provider Demographics
NPI:1134337710
Name:IM SPECIALIST, INC
Entity type:Organization
Organization Name:IM SPECIALIST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARI
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-437-4800
Mailing Address - Street 1:2737 W BASELINE RD
Mailing Address - Street 2:SUITE 24
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1051
Mailing Address - Country:US
Mailing Address - Phone:602-437-4800
Mailing Address - Fax:602-437-4805
Practice Address - Street 1:2737 W BASELINE RD
Practice Address - Street 2:SUITE 24
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1051
Practice Address - Country:US
Practice Address - Phone:602-437-4800
Practice Address - Fax:602-437-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0767620OtherBCBS OF AZ
AZ425993Medicaid
AZAZ0767620OtherBCBS OF AZ
AZ425993Medicaid
AZ=========OtherTAX ID
AZG58518Medicare UPIN