Provider Demographics
NPI:1780054759
Name:PHOENICIAN FAMILY MEDICINE
Entity type:Organization
Organization Name:PHOENICIAN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-979-0309
Mailing Address - Street 1:5114 W PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-1618
Mailing Address - Country:US
Mailing Address - Phone:623-979-0309
Mailing Address - Fax:
Practice Address - Street 1:5114 W PEORIA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-1618
Practice Address - Country:US
Practice Address - Phone:623-979-0309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty