Healthcare Provider Details

I. General information

NPI: 1497045769
Provider Name (Legal Business Name): ERIN TKACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 W THUNDERBIRD RD UNIT 2ND
GLENDALE AZ
85306-4622
US

IV. Provider business mailing address

1341 E PASEO WAY
PHOENIX AZ
85042-8393
US

V. Phone/Fax

Practice location:
  • Phone: 602-865-4647
  • Fax:
Mailing address:
  • Phone: 814-404-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number53732
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: