Healthcare Provider Details

I. General information

NPI: 1467060343
Provider Name (Legal Business Name): GEROPSYCHMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9618 N 35TH PL
PHOENIX AZ
85028-4934
US

IV. Provider business mailing address

9618 N 35TH PL
PHOENIX AZ
85028-4934
US

V. Phone/Fax

Practice location:
  • Phone: 602-930-2248
  • Fax: 623-399-9958
Mailing address:
  • Phone: 602-930-2248
  • Fax: 623-399-9958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY J FRAZIER
Title or Position: PHYSICIAN/SOLE MEMBER
Credential: MD
Phone: 602-930-2248