Healthcare Provider Details

I. General information

NPI: 1669845558
Provider Name (Legal Business Name): CASELLI AVENUE PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 N 7TH ST 9812 N. 7TH STREET
PHOENIX AZ
85020-1763
US

IV. Provider business mailing address

9812 N 7TH ST 9812 N7TH STREET SUITE 7
PHOENIX AZ
85020-1763
US

V. Phone/Fax

Practice location:
  • Phone: 602-714-6783
  • Fax: 602-325-0125
Mailing address:
  • Phone: 602-714-6783
  • Fax: 602-325-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number27081
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number27081
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27081
License Number StateAZ

VIII. Authorized Official

Name: JOHN SUTHERLAND
Title or Position: CEO
Credential: M.D.
Phone: 602-714-6783