MEDICARE: THIRTY THIRD AVENUE MEDICAL LLC

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	261QU0200X	Urgent Care Clinic/Center	OTC2674	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518945120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRTY THIRD AVENUE MEDICAL LLC

Provider Business Mailing Address
First Line	:	PO BOX 32950
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85064
Country	:	US
Telephone Number	:	602-433-1822
Fax Number	:	602-246-7060

Provider Business Practice Location Address
First Line	:	3302 W THOMAS RD
Second Line	:	#10
City	:	PHOENIX
State	:	AZ
Zip	:	85017
Country	:	US
Telephone Number	:	602-233-2900
Fax Number	:	602-233-3897

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MRS. RENEE L BISKUPSKI
Credential	:
Telephone Number	:	602-433-1822

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	03/19/2008

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