Healthcare Provider Details

I. General information

NPI: 1629616727
Provider Name (Legal Business Name): IMD PHYSICIANS ARIZONA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 N 16TH ST STE 104
PHOENIX AZ
85020-5214
US

IV. Provider business mailing address

4325 E GLACIER PLACE
PHOENIX AZ
85029-5653
US

V. Phone/Fax

Practice location:
  • Phone: 602-714-2815
  • Fax:
Mailing address:
  • Phone: 602-318-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICAH D HALE
Title or Position: CEO
Credential: DO
Phone: 831-818-9833