MEDICARE: IMD PHYSICIANS ARIZONA 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	261QM1300X	Multi-Specialty Clinic/Center
2	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician

General Provider Information

NPI Number	:	1629616727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMD PHYSICIANS ARIZONA PLLC

Provider Business Mailing Address
First Line	:	4325 E GLACIER PLACE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-5653
Country	:	US
Telephone Number	:	602-318-7878
Fax Number	:

Provider Business Practice Location Address
First Line	:	7250 N 16TH ST STE 104
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85020-5214
Country	:	US
Telephone Number	:	602-714-2815
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MICAH D HALE
Credential	:	DO
Telephone Number	:	831-818-9833

Provider Enumeration Date	:	12/19/2019
Last Update Date	:	03/24/2020

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