Provider Demographics
NPI:1811078686
Name:FOOTHILLS PRIMARY CARE LLC
Entity type:Organization
Organization Name:FOOTHILLS PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:RISKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-496-0000
Mailing Address - Street 1:PO BOX 29675
Mailing Address - Street 2:DEPT 2061
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9675
Mailing Address - Country:US
Mailing Address - Phone:480-496-0000
Mailing Address - Fax:480-496-7325
Practice Address - Street 1:600 S DOBSON RD
Practice Address - Street 2:SUITE D27
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5678
Practice Address - Country:US
Practice Address - Phone:480-496-0000
Practice Address - Fax:480-496-7325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ113363Medicare PIN
AZF58892Medicare UPIN