Healthcare Provider Details

I. General information

NPI: 1710099643
Provider Name (Legal Business Name): CMG AUDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 N NORTERRA DR ATTN: HCFS
PHOENIX AZ
85085-8200
US

IV. Provider business mailing address

25500 N NORTERRA DR ATTN: HCFS
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 602-328-8400
  • Fax:
Mailing address:
  • Phone: 602-328-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: KEVIN ELLIS
Title or Position: CHIEF MEDICAL DIRECTOR
Credential: DO
Phone: 623-277-2246