Healthcare Provider Details

I. General information

NPI: 1699221879
Provider Name (Legal Business Name): GATEWAY ADDICTIONOLOGY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4862 E. BASELINE ROAD SUITE 108
MESA AZ
85206
US

IV. Provider business mailing address

4838 E. BASELINE ROAD SUITE 108
MESA AZ
85206-4672
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-2405
  • Fax: 480-981-2407
Mailing address:
  • Phone: 480-981-2400
  • Fax: 480-981-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number43504
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH5407
License Number StateAZ

VIII. Authorized Official

Name: BRIAN J. DELISIO
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 480-981-2405