Healthcare Provider Details

I. General information

NPI: 1366081705
Provider Name (Legal Business Name): DISTRICT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 W ANTHEM WAY STE C116
ANTHEM AZ
85086-0457
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 623-434-5748
  • Fax: 623-551-8882
Mailing address:
  • Phone: 602-470-5000
  • Fax: 602-470-5064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA CORDEIRO
Title or Position: DIRECTOR, CREDENTIALING
Credential:
Phone: 602-470-5519