MEDICARE: FITZGERALD PROFESSIONAL CORPORATION

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	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1801049010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FITZGERALD PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	7054 EAST COCHISE RD
Second Line	:	B-230
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85253-4550
Country	:	US
Telephone Number	:	480-922-9220
Fax Number	:	480-922-0575

Provider Business Practice Location Address
First Line	:	7054 EAST COCHISE RD
Second Line	:	B-230
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85253-4550
Country	:	US
Telephone Number	:	480-922-9220
Fax Number	:	480-922-0575

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MARVIN H. FITZGERALD
Credential	:
Telephone Number	:	480-922-9220

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	10/31/2008

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