Healthcare Provider Details

I. General information

NPI: 1043400427
Provider Name (Legal Business Name): CHARLES ROUNDS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151-6153 W OLIVE AVE
GLENDALE AZ
85302-4598
US

IV. Provider business mailing address

15050 N 6TH ST
PHOENIX AZ
85022-3615
US

V. Phone/Fax

Practice location:
  • Phone: 602-685-6000
  • Fax: 602-389-3599
Mailing address:
  • Phone: 623-202-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3683
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number3683
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3683
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: