1467656991 NPI number — MARYVALE INTEGRATED MEDICAL GROUP - LLC

Table of content: (NPI 1467656991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467656991 NPI number — MARYVALE INTEGRATED MEDICAL GROUP - LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYVALE INTEGRATED MEDICAL GROUP - LLC
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:
1467656991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5251 W CAMPBELL AVE
Provider Second Line Business Mailing Address:
STE 206
Provider Business Mailing Address City Name:
PHONEIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-848-3020
Provider Business Mailing Address Fax Number:
623-848-3019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5251 W CAMPBELL AVE
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
PHONEIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-848-3020
Provider Business Practice Location Address Fax Number:
623-848-3019
Provider Enumeration Date:
06/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MD PRESIDENT
Authorized Official Telephone Number:
623-848-3295

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com