Provider Demographics
NPI:1649330812
Name:KATHLEEN GERACE DOPC
Entity type:Organization
Organization Name:KATHLEEN GERACE DOPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GERACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-941-4400
Mailing Address - Street 1:6401 EAST THOMAS ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6078
Mailing Address - Country:US
Mailing Address - Phone:480-941-4400
Mailing Address - Fax:480-941-1100
Practice Address - Street 1:6401 E THOMAS RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6078
Practice Address - Country:US
Practice Address - Phone:480-941-4400
Practice Address - Fax:480-941-1100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3082174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ378522OtherAHCCCS
AZAZ0803970OtherBCBS
AZ378522OtherAHCCCS
AZG44299Medicare UPIN