Provider Demographics
NPI:1649455296
Name:WESTERN FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:WESTERN FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-222-7664
Mailing Address - Street 1:2730 S VAL VISTA DR
Mailing Address - Street 2:BLDG 9 STE 152
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1675
Mailing Address - Country:US
Mailing Address - Phone:480-222-7664
Mailing Address - Fax:480-222-7666
Practice Address - Street 1:2730 S VAL VISTA DR
Practice Address - Street 2:BLDG 9 STE 152
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1675
Practice Address - Country:US
Practice Address - Phone:480-222-7664
Practice Address - Fax:480-222-7666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ108034Medicare PIN
AZI22071Medicare UPIN