MEDICARE: AGAVE FAMILY MEDICINE

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	207Q00000X	Family Medicine Physician	33407	AZ

General Provider Information

NPI Number	:	1407809387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAVE FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 43100
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85733-3100
Country	:	US
Telephone Number	:	520-722-3777
Fax Number	:

Provider Business Practice Location Address
First Line	:	8710 N THORNYDALE RD
Second Line	:	STE 160
City	:	TUCSON
State	:	AZ
Zip	:	85742-5031
Country	:	US
Telephone Number	:	520-744-2441
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHARLES A MICHIELI
Credential	:	MD
Telephone Number	:	520-744-2441

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	08/22/2020

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