Healthcare Provider Details

I. General information

NPI: 1790050409
Provider Name (Legal Business Name): SCOTTSDALE INTERNAL MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 N 12TH ST STE 101
PHOENIX AZ
85014-4083
US

IV. Provider business mailing address

4643 N 12TH ST STE 101
PHOENIX AZ
85014-4083
US

V. Phone/Fax

Practice location:
  • Phone: 602-812-3789
  • Fax:
Mailing address:
  • Phone: 602-812-3789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES BENJAMIN EVANS II
Title or Position: OWNER
Credential: MD
Phone: 602-292-0552