Healthcare Provider Details

I. General information

NPI: 1154957678
Provider Name (Legal Business Name): INFINITY MEDICAL PROVIDERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E EVA ST
PHOENIX AZ
85020-2564
US

IV. Provider business mailing address

21001 N TATUM BLVD STE 1630 BOX 941
PHOENIX AZ
85050-4242
US

V. Phone/Fax

Practice location:
  • Phone: 773-410-1676
  • Fax:
Mailing address:
  • Phone: 602-699-4066
  • Fax: 480-275-4229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREEM MCCLESKEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-699-4066