Healthcare Provider Details

I. General information

NPI: 1053657361
Provider Name (Legal Business Name): GENESIS MEDICAL PRACTICE MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 N 16TH ST E-110
PHOENIX AZ
85016-5121
US

IV. Provider business mailing address

4620 N 16TH ST E-110
PHOENIX AZ
85016-5121
US

V. Phone/Fax

Practice location:
  • Phone: 602-264-2770
  • Fax: 866-534-1701
Mailing address:
  • Phone: 602-264-2770
  • Fax: 866-534-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. DARYL C. MILLAR
Title or Position: CEO
Credential:
Phone: 602-264-2770