Healthcare Provider Details

I. General information

NPI: 1891831228
Provider Name (Legal Business Name): INFECTIOUS DISEASE CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 W UNION HILLS DR SUITE # 7-280
GLENDALE AZ
85308-1660
US

IV. Provider business mailing address

4410 W UNION HILLS DR SUITE # 7-280
GLENDALE AZ
85308-1660
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-6611
  • Fax: 623-974-9434
Mailing address:
  • Phone: 623-974-6611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL M SHANAHAN
Title or Position: BILLING MANAGER
Credential:
Phone: 623-974-6611