Healthcare Provider Details

I. General information

NPI: 1659402998
Provider Name (Legal Business Name): EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4858 E BASELINE RD SUITE 107
MESA AZ
85206-4638
US

IV. Provider business mailing address

4858 E BASELINE RD STE 107
MESA AZ
85206-4638
US

V. Phone/Fax

Practice location:
  • Phone: 480-807-6500
  • Fax: 866-835-7591
Mailing address:
  • Phone: 480-807-6500
  • Fax: 866-835-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number33084
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number33084
License Number StateAZ

VIII. Authorized Official

Name: DR. TUTANKHAMEN ALLOTEY PAPPOE
Title or Position: OWNER AND PHYSICIAN
Credential: M.D.
Phone: 480-807-6500