Healthcare Provider Details

I. General information

NPI: 1508427667
Provider Name (Legal Business Name): ARIZONA STATE UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 W SACK DR STE 201
GLENDALE AZ
85308-7106
US

IV. Provider business mailing address

6525 W SACK DR STE 201
GLENDALE AZ
85308-7106
US

V. Phone/Fax

Practice location:
  • Phone: 602-337-8500
  • Fax: 602-337-8151
Mailing address:
  • Phone: 602-337-8500
  • Fax: 602-337-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA J KIM TAY
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-337-8500