Healthcare Provider Details

I. General information

NPI: 1164500187
Provider Name (Legal Business Name): JOHN C LINCOLN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18404 N TATUM BLVD SUITE 101
PHOENIX AZ
85032-1510
US

IV. Provider business mailing address

2500 W UTOPIA RD SUITE 100
PHOENIX AZ
85027-4171
US

V. Phone/Fax

Practice location:
  • Phone: 602-992-1900
  • Fax: 602-485-7440
Mailing address:
  • Phone: 623-434-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberOTC3148
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOTC 1780
License Number StateAZ

VIII. Authorized Official

Name: NATHAN ANSPACH
Title or Position: SR. VICE PRESIDENT
Credential:
Phone: 623-434-6200