MEDICARE: ARIZONA MINIMALLY INVASIVE SINUS INSTITUTE PLLC

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	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1376985549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA MINIMALLY INVASIVE SINUS INSTITUTE PLLC

Provider Business Mailing Address
First Line	:	19636 N 27TH AVE STE 206
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4015
Country	:	US
Telephone Number	:	602-788-0088
Fax Number	:	602-931-4544

Provider Business Practice Location Address
First Line	:	19636 N 27TH AVE STE 206
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-4015
Country	:	US
Telephone Number	:	602-788-0088
Fax Number	:	602-931-4544

Authorized Official
Title or Position	:	MANAGER
Name	:	SUSAN L TRAIKOVICH
Credential	:
Telephone Number	:	623-516-0930

Provider Enumeration Date	:	07/29/2013
Last Update Date	:	01/06/2019

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