Healthcare Provider Details

I. General information

NPI: 1205996667
Provider Name (Legal Business Name): GLENDALE OBSTETRICS AND GYNECOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD SUITE D400
GLENDALE AZ
85306
US

IV. Provider business mailing address

5750 W THUNDERBIRD SUITE D400
GLENDALE AZ
85306
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-8977
  • Fax: 602-298-1787
Mailing address:
  • Phone: 602-298-8977
  • Fax: 602-298-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: WADDY MCFALL
Title or Position: ADMINISTRATOR SEC TREAS
Credential:
Phone: 602-298-8977