Healthcare Provider Details

I. General information

NPI: 1740224054
Provider Name (Legal Business Name): ALLIANCE MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42104 N VENTURE DR SUITE D118
ANTHEM AZ
85086-3823
US

IV. Provider business mailing address

42104 N VENTURE DR SUITE D 118
ANTHEM AZ
85086-3823
US

V. Phone/Fax

Practice location:
  • Phone: 623-505-6565
  • Fax: 623-551-5567
Mailing address:
  • Phone: 623-505-6565
  • Fax: 623-505-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALICIA ANNE BAER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 623-271-8704