Provider Demographics
NPI:1982891115
Name:COMPREHENSIVE BREAST CENTER OF ARIZONA, PLC
Entity Type:Organization
Organization Name:COMPREHENSIVE BREAST CENTER OF ARIZONA, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:BRENDA
Authorized Official - Last Name:MOORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-374-3440
Mailing Address - Street 1:9179 W THUNDERBIRD RD
Mailing Address - Street 2:103
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4875
Mailing Address - Country:US
Mailing Address - Phone:602-374-3440
Mailing Address - Fax:602-374-3441
Practice Address - Street 1:9179 W THUNDERBIRD RD
Practice Address - Street 2:103
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4875
Practice Address - Country:US
Practice Address - Phone:602-374-3440
Practice Address - Fax:602-374-3441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4264208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
105045Medicare PIN