Healthcare Provider Details

I. General information

NPI: 1487631883
Provider Name (Legal Business Name): MED 97 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 W INDIAN SCHOOL RD STE 1 & 2
PHOENIX AZ
85033
US

IV. Provider business mailing address

PO BOX 32950
PHOENIX AZ
85064
US

V. Phone/Fax

Practice location:
  • Phone: 623-846-7122
  • Fax: 623-846-7027
Mailing address:
  • Phone: 602-433-1822
  • Fax: 602-246-7060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberOTC2677
License Number StateAZ

VIII. Authorized Official

Name: RENEE L BISKUPSKI
Title or Position: VP OF OPERATIONS
Credential:
Phone: 602-433-1822