Healthcare Provider Details

I. General information

NPI: 1740256270
Provider Name (Legal Business Name): C ROGER BIRD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W THOMAS RD
PHOENIX AZ
85013-4409
US

IV. Provider business mailing address

PO BOX 27340
PHOENIX AZ
85061-7340
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-3000
  • Fax:
Mailing address:
  • Phone: 602-943-9200
  • Fax: 602-216-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number16741
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number16741
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: