Healthcare Provider Details

I. General information

NPI: 1295705903
Provider Name (Legal Business Name): EDWARD HENRY WINTERGALEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4527
US

IV. Provider business mailing address

645 E MISSOURI AVE STE 300
PHOENIX AZ
85012-1351
US

V. Phone/Fax

Practice location:
  • Phone: 602-744-4765
  • Fax: 602-744-4799
Mailing address:
  • Phone: 602-262-8900
  • Fax: 602-262-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number23976
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: