Healthcare Provider Details

I. General information

NPI: 1093019150
Provider Name (Legal Business Name): SPRINGFIELD MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36351 N GANTZEL RD STE 127
SAN TAN VALLEY AZ
85140-7329
US

IV. Provider business mailing address

36351 N GANTZEL RD STE 127
SAN TAN VALLEY AZ
85140-7329
US

V. Phone/Fax

Practice location:
  • Phone: 602-734-5509
  • Fax: 877-281-3385
Mailing address:
  • Phone: 602-734-5509
  • Fax: 877-281-3385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40162
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number40162
License Number StateAZ

VIII. Authorized Official

Name: OLADIJI G VAUGHAN
Title or Position: OWNER
Credential: MD
Phone: 602-734-5509