Healthcare Provider Details

I. General information

NPI: 1073609848
Provider Name (Legal Business Name): JOHN C LINCOLN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3648 W ANTHEM WAY SUITE A100
ANTHEM AZ
85086
US

IV. Provider business mailing address

2500 W UTOPIA RD SUITE 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 602-485-7482
  • Fax: 623-434-6448
Mailing address:
  • Phone: 623-434-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOTC 3490
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberOTC3148
License Number StateAZ

VIII. Authorized Official

Name: NATHAN ANSPACH
Title or Position: SR. VP
Credential:
Phone: 623-434-6200