1770647380 NPI number — GILBERT ROAD FAMILY MEDICINE PC

Table of content: (NPI 1770647380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770647380 NPI number — GILBERT ROAD FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GILBERT ROAD FAMILY MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770647380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
643 N GILBERT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85203-6659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-898-9686
Provider Business Mailing Address Fax Number:
480-898-1092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
643 N GILBERT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85203-6659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-898-9686
Provider Business Practice Location Address Fax Number:
480-898-1092
Provider Enumeration Date:
12/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-898-9686

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  1788 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 26874 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 26874 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)