Healthcare Provider Details

I. General information

NPI: 1396277190
Provider Name (Legal Business Name): MPM GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11047 N 19TH AVE
PHOENIX AZ
85029-4816
US

IV. Provider business mailing address

11047 N 19TH AVE
PHOENIX AZ
85029-4816
US

V. Phone/Fax

Practice location:
  • Phone: 602-944-2222
  • Fax:
Mailing address:
  • Phone: 602-944-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HERBERT GOODMAN
Title or Position: MANAGER
Credential:
Phone: 602-944-2222