Healthcare Provider Details

I. General information

NPI: 1871563692
Provider Name (Legal Business Name): CHARLES PETER DRIES JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE SUITE 1600
PHOENIX AZ
85004-4633
US

IV. Provider business mailing address

1850 N CENTRAL AVE SUITE 1600
PHOENIX AZ
85004-4633
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number21996
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number21996
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: