Healthcare Provider Details

I. General information

NPI: 1144624339
Provider Name (Legal Business Name): DISTRICT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2014
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST EMERGENCY MEDICINE
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

2929 E THOMAS RD
PHOENIX AZ
85016-8034
US

V. Phone/Fax

Practice location:
  • Phone: 602-470-5011
  • Fax:
Mailing address:
  • Phone: 602-470-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: TERESA CORDEIRO
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 602-470-5000