Healthcare Provider Details

I. General information

NPI: 1417986118
Provider Name (Legal Business Name): INGENUITY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 E THOMAS RD
PHOENIX AZ
85016-7711
US

IV. Provider business mailing address

80 E RIO SALADO PKWY STE 703
TEMPE AZ
85281-9110
US

V. Phone/Fax

Practice location:
  • Phone: 480-296-6549
  • Fax:
Mailing address:
  • Phone: 480-247-9195
  • Fax: 480-588-8027

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 Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK A. SMITH
Title or Position: BUSINESS MANAGER
Credential:
Phone: 480-296-6549