Healthcare Provider Details

I. General information

NPI: 1376160309
Provider Name (Legal Business Name): AMG PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 E BASELINE RD STE 121
GILBERT AZ
85234-2969
US

IV. Provider business mailing address

1925 S FOLLETT WAY
GILBERT AZ
85295-0155
US

V. Phone/Fax

Practice location:
  • Phone: 480-812-3668
  • Fax:
Mailing address:
  • Phone: 360-269-2106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: ANDREW GOODEILL
Title or Position: OWNER/MEMBER
Credential: DPM
Phone: 360-269-2106