Healthcare Provider Details

I. General information

NPI: 1235501370
Provider Name (Legal Business Name): TRAUMA & RECONSTRUCTIVE UPPER EXTREMITY SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E VIRGINIA AVE STE 100
PHOENIX AZ
85004-1254
US

IV. Provider business mailing address

370 E VIRGINIA AVE STE 100
PHOENIX AZ
85004-1254
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-5611
  • Fax:
Mailing address:
  • Phone: 602-222-5611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number28314
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number28314
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number28314
License Number StateAZ

VIII. Authorized Official

Name: MS. KATHERINE C WHITE
Title or Position: CPA AGENT
Credential: CPA
Phone: 602-222-5611