Healthcare Provider Details

I. General information

NPI: 1609338102
Provider Name (Legal Business Name): MICHAEL BEHROOZ HENRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

4248 N 15TH DR
PHOENIX AZ
85015-4711
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5808
  • Fax:
Mailing address:
  • Phone: 717-557-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number65593
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: