Healthcare Provider Details

I. General information

NPI: 1689664658
Provider Name (Legal Business Name): MICHAEL GARY SILLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18404 N. TATUM BLVD SUITE 103
PHOENIX AZ
85032
US

IV. Provider business mailing address

2500 W UTOPIA RD STE. 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 602-485-7491
  • Fax: 623-780-3752
Mailing address:
  • Phone: 602-214-6148
  • Fax: 602-214-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number27492
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: