Healthcare Provider Details

I. General information

NPI: 1710198783
Provider Name (Legal Business Name): MARICOPA OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 E CAMELBACK RD SUITE 160
PHOENIX AZ
85016-3911
US

IV. Provider business mailing address

1661 E CAMELBACK RD SUITE 160
PHOENIX AZ
85016-3911
US

V. Phone/Fax

Practice location:
  • Phone: 602-241-1674
  • Fax: 602-230-7982
Mailing address:
  • Phone: 602-241-1674
  • Fax: 602-230-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACIANNE JOHNSON
Title or Position: HIPAA OFFICER
Credential:
Phone: 623-551-0192