Provider Demographics
NPI:1356609077
Name:INFECTIOUS DISEASE CONSULTANTS PLLC
Entity type:Organization
Organization Name:INFECTIOUS DISEASE CONSULTANTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:TODD MARTIN
Authorized Official - Last Name:THORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-229-3300
Mailing Address - Street 1:PO BOX 16125
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-6125
Mailing Address - Country:US
Mailing Address - Phone:520-989-0226
Mailing Address - Fax:520-989-3798
Practice Address - Street 1:2001 W ORANGE GROVE RD
Practice Address - Street 2:SUITE 404
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1139
Practice Address - Country:US
Practice Address - Phone:520-989-0226
Practice Address - Fax:520-989-3798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ711418Medicaid