MEDICARE: EAST VALLEY PRIMARY CARE PHYSICIANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	18615	AZ

General Provider Information

NPI Number	:	1023014883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY PRIMARY CARE PHYSICIANS

Provider Business Mailing Address
First Line	:	4515 S MCCLINTOCK DR
Second Line	:	STE 100
City	:	TEMPE
State	:	AZ
Zip	:	85282-7381
Country	:	US
Telephone Number	:	480-820-1133
Fax Number	:	480-820-9292

Provider Business Practice Location Address
First Line	:	4515 S MCCLINTOCK DR
Second Line	:	STE 100
City	:	TEMPE
State	:	AZ
Zip	:	85282-7381
Country	:	US
Telephone Number	:	480-820-1133
Fax Number	:	480-820-9292

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. FLORA A CAMACHO
Credential	:
Telephone Number	:	480-820-1133

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	08/22/2020

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1770589491 — TRACEY L MARTIN MD
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