Healthcare Provider Details

I. General information

NPI: 1649554940
Provider Name (Legal Business Name): TRI-CITY EXPRESS CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 S SIGNAL BUTTE RD SUITE 103
MESA AZ
85209-2608
US

IV. Provider business mailing address

890 W ELLIOT RD SUITE 103
GILBERT AZ
85233-5102
US

V. Phone/Fax

Practice location:
  • Phone: 480-214-4466
  • Fax: 480-360-1185
Mailing address:
  • Phone: 480-545-2787
  • Fax: 480-545-1413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberOTC5221
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier675135
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL P. DUNN
Title or Position: PRESIDENT/CMO
Credential: MD
Phone: 480-545-2787