Healthcare Provider Details

I. General information

NPI: 1285006957
Provider Name (Legal Business Name): PVIM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 W PEORIA AVE SUITE 115A
GLENDALE AZ
85302-2023
US

IV. Provider business mailing address

4494 W PEORIA AVE SUITE 115A
GLENDALE AZ
85302-2023
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-5800
  • Fax: 623-773-2274
Mailing address:
  • Phone: 623-878-5800
  • Fax: 623-773-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALLYSON K MORGAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-695-7392