Provider Demographics
NPI:1811491780
Name:FORD MEDICAL TREATMENT CENTER
Entity type:Organization
Organization Name:FORD MEDICAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ADELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-326-1055
Mailing Address - Street 1:11624 E BELLFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249-4525
Mailing Address - Country:US
Mailing Address - Phone:623-326-1055
Mailing Address - Fax:
Practice Address - Street 1:11624 E BELLFLOWER DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249-4525
Practice Address - Country:US
Practice Address - Phone:623-326-1055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID