Healthcare Provider Details

I. General information

NPI: 1932648607
Provider Name (Legal Business Name): MOBILE DOC ALLIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 E CAMELBACK RD STE 615
PHOENIX AZ
85016-3458
US

IV. Provider business mailing address

2355 E CAMELBACK RD STE 615
PHOENIX AZ
85016-3458
US

V. Phone/Fax

Practice location:
  • Phone: 480-359-3998
  • Fax: 480-385-6785
Mailing address:
  • Phone: 480-359-3998
  • Fax: 480-385-6785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MAI SHANNON
Title or Position: MANAGING MEMBER
Credential:
Phone: 480-359-3998