Provider Demographics
NPI:1265756977
Name:PHOENIX DIABETES AND ENDOCRINOLOGY, LLC
Entity type:Organization
Organization Name:PHOENIX DIABETES AND ENDOCRINOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-788-3636
Mailing Address - Street 1:4045 E UNION HILLS DR
Mailing Address - Street 2:A-107
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-3386
Mailing Address - Country:US
Mailing Address - Phone:602-788-3636
Mailing Address - Fax:602-788-3646
Practice Address - Street 1:4045 E UNION HILLS DR
Practice Address - Street 2:A107
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3386
Practice Address - Country:US
Practice Address - Phone:602-788-3636
Practice Address - Fax:602-788-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25915207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ509712Medicaid
AZZ139147Medicare PIN
AZ509712Medicaid