Healthcare Provider Details

I. General information

NPI: 1194803056
Provider Name (Legal Business Name): MARTINE MARIE HANNALLAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13991 W GRAND AVE SUITE 105
SURPRISE AZ
85374-3065
US

IV. Provider business mailing address

25500 N NORTERRA DR
PHOENIX AZ
85085-8200
US

V. Phone/Fax

Practice location:
  • Phone: 623-455-7800
  • Fax: 623-455-7840
Mailing address:
  • Phone: 623-277-1000
  • Fax: 623-866-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29532
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: