Provider Demographics
NPI:1205996667
Name:GLENDALE OBSTETRICS AND GYNECOLOGY PC
Entity type:Organization
Organization Name:GLENDALE OBSTETRICS AND GYNECOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR SEC TREAS
Authorized Official - Prefix:
Authorized Official - First Name:WADDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCFALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-298-8977
Mailing Address - Street 1:5750 W THUNDERBIRD
Mailing Address - Street 2:SUITE D400
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306
Mailing Address - Country:US
Mailing Address - Phone:602-298-8977
Mailing Address - Fax:602-298-1787
Practice Address - Street 1:5750 W THUNDERBIRD
Practice Address - Street 2:SUITE D400
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-298-8977
Practice Address - Fax:602-298-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z27533Medicare PIN