Provider Demographics
NPI:1154774305
Name:MESA PHYSICAL MEDICINE PLLC
Entity type:Organization
Organization Name:MESA PHYSICAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-907-1322
Mailing Address - Street 1:2919 S ELLSWORTH RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2164
Mailing Address - Country:US
Mailing Address - Phone:480-354-2008
Mailing Address - Fax:
Practice Address - Street 1:2919 S ELLSWORTH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2164
Practice Address - Country:US
Practice Address - Phone:480-354-2008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4338363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty