Healthcare Provider Details

I. General information

NPI: 1376154625
Provider Name (Legal Business Name): MEMD PROVIDER NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6910 E CHAUNCEY LN STE 220
PHOENIX AZ
85054-5162
US

IV. Provider business mailing address

6910 E CHAUNCEY LN STE 220
PHOENIX AZ
85054-5162
US

V. Phone/Fax

Practice location:
  • Phone: 480-339-4573
  • Fax:
Mailing address:
  • Phone: 480-339-4573
  • Fax:

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 Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLENN DEAN
Title or Position: CFO
Credential:
Phone: 480-339-4573