Healthcare Provider Details

I. General information

NPI: 1548984800
Provider Name (Legal Business Name): HEALTHSPANMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E HIGHLAND AVE STE 222
PHOENIX AZ
85016-4876
US

IV. Provider business mailing address

4808 N 24TH ST UNIT 1103
PHOENIX AZ
85016-9113
US

V. Phone/Fax

Practice location:
  • Phone: 480-847-2575
  • Fax:
Mailing address:
  • Phone: 480-847-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT TODD HURST
Title or Position: OWNER
Credential: MD
Phone: 480-847-2575