Healthcare Provider Details

I. General information

NPI: 1659787497
Provider Name (Legal Business Name): MCKELLIPS FAMILY MEDICAL CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 N POWER RD BLDG. 1, SUITE 105
MESA AZ
85215-8521
US

IV. Provider business mailing address

3514 N POWER RD STE 105
MESA AZ
85215-2907
US

V. Phone/Fax

Practice location:
  • Phone: 480-422-8533
  • Fax:
Mailing address:
  • Phone: 480-422-8533
  • Fax: 480-981-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARL FERGUSON
Title or Position: PROVIDER
Credential: DO
Phone: 480-830-1553