Provider Demographics
NPI:1669428363
Name:ANASAZI MEDICAL CLINIC PC
Entity type:Organization
Organization Name:ANASAZI MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-398-2022
Mailing Address - Street 1:6641 EAST BAYWOOD AVE
Mailing Address - Street 2:SUITE #A2
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206
Mailing Address - Country:US
Mailing Address - Phone:480-396-2022
Mailing Address - Fax:480-396-2035
Practice Address - Street 1:6641 EAST BAYWOOD AVE
Practice Address - Street 2:SUITE #A2
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:480-396-2022
Practice Address - Fax:480-396-2035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22725207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ78972Medicare PIN