Provider Demographics
NPI:1457602575
Name:ARIZONA CENTER FOR NEUROLOGIC MEDICINE
Entity Type:Organization
Organization Name:ARIZONA CENTER FOR NEUROLOGIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-200-6999
Mailing Address - Street 1:2702 N 3RD ST
Mailing Address - Street 2:SUITE 2007
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1130
Mailing Address - Country:US
Mailing Address - Phone:602-200-6999
Mailing Address - Fax:602-200-6990
Practice Address - Street 1:2702 N 3RD ST
Practice Address - Street 2:SUITE 2007
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1130
Practice Address - Country:US
Practice Address - Phone:602-200-6999
Practice Address - Fax:602-200-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21445174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF54224Medicare UPIN
AZZMD21445Medicare PIN