MEDICARE: CLEANSLATE MEDICAL GROUP OF 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

General Provider Information

NPI Number	:	1801421656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEANSLATE MEDICAL GROUP OF ARIZONA PLLC

Provider Business Mailing Address
First Line	:	8 CADILLAC DR STE 300
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-5337
Country	:	US
Telephone Number	:	615-425-0220
Fax Number	:	833-279-7074

Provider Business Practice Location Address
First Line	:	15255 N 40TH ST STE 135
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-4682
Country	:	US
Telephone Number	:	480-417-4215
Fax Number	:	833-279-7074

Authorized Official
Title or Position	:	CFO
Name	:	MATTHEW PHILIP SMOLAREK
Credential	:
Telephone Number	:	412-999-5188

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	12/01/2025

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