Healthcare Provider Details

I. General information

NPI: 1770798852
Provider Name (Legal Business Name): OSTEOPATHIC MEDICAL CENTER OF SCOTTSDALE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 N 90TH ST C-121
SCOTTSDALE AZ
85258-5046
US

IV. Provider business mailing address

9755 N 90TH ST C-121
SCOTTSDALE AZ
85258-5046
US

V. Phone/Fax

Practice location:
  • Phone: 480-391-7631
  • Fax: 480-314-5493
Mailing address:
  • Phone: 480-391-7631
  • Fax: 480-314-5493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberDO2849
License Number StateAZ

VIII. Authorized Official

Name: VICTORIA A TRONCOSO
Title or Position: PROVIDER
Credential: D.O.
Phone: 480-391-7631