Healthcare Provider Details

I. General information

NPI: 1982934204
Provider Name (Legal Business Name): CENTER FOR SEXUAL AND URINARY FUNCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20325 N 51ST AVE STE 102
GLENDALE AZ
85308-5665
US

IV. Provider business mailing address

20325 N 51ST AVE STE 102
GLENDALE AZ
85308-5665
US

V. Phone/Fax

Practice location:
  • Phone: 623-780-2300
  • Fax: 623-582-9666
Mailing address:
  • Phone: 623-780-2300
  • Fax: 623-582-9666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number34718
License Number StateAZ

VIII. Authorized Official

Name: DR. PETER NIEMCZYK
Title or Position: DIRECTOR
Credential: M.D.
Phone: 602-531-5824