Provider Demographics
NPI:1740478890
Name:CRAIG M. PHELPS, D.O., FAOASM,PC
Entity type:Organization
Organization Name:CRAIG M. PHELPS, D.O., FAOASM,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDIENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-588-4040
Mailing Address - Street 1:4344 W BELL RD
Mailing Address - Street 2:SUITE102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3589
Mailing Address - Country:US
Mailing Address - Phone:602-588-4040
Mailing Address - Fax:602-588-4034
Practice Address - Street 1:4344 W BELL RD
Practice Address - Street 2:SUITE102
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3589
Practice Address - Country:US
Practice Address - Phone:602-588-4040
Practice Address - Fax:602-588-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ100276Medicare PIN