Healthcare Provider Details

I. General information

NPI: 1447884929
Provider Name (Legal Business Name): PHOENIX SURGICAL DERMATOLOGY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/29/2020
Certification Date: 02/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 E BELL RD BLDG 5
PHOENIX AZ
85032-9390
US

IV. Provider business mailing address

4550 E BELL RD BLDG 5
PHOENIX AZ
85032-9390
US

V. Phone/Fax

Practice location:
  • Phone: 480-666-5568
  • Fax: 702-297-6238
Mailing address:
  • Phone: 480-666-5568
  • Fax: 702-297-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RAMIN FATHI
Title or Position: OWNER
Credential: MD
Phone: 480-666-5568