MEDICARE: PHOENICIAN 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	006374	AZ

General Provider Information

NPI Number	:	1780054759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENICIAN FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	5114 W PEORIA AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-1618
Country	:	US
Telephone Number	:	623-979-0309
Fax Number	:

Provider Business Practice Location Address
First Line	:	5114 W PEORIA AVE
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85302-1618
Country	:	US
Telephone Number	:	623-979-0309
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MD
Name	:	SCOTT MARQUARD
Credential	:	MD
Telephone Number	:	623-979-0309

Provider Enumeration Date	:	10/02/2015
Last Update Date	:	10/02/2015

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Directions to “PHOENICIAN FAMILY MEDICINE ” Practice Location

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