Healthcare Provider Details

I. General information

NPI: 1730748435
Provider Name (Legal Business Name): NEXT GEN MEDICUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 S COTTONWOOD DR
TEMPE AZ
85282-3040
US

IV. Provider business mailing address

2075 S COTTONWOOD DR
TEMPE AZ
85282-3040
US

V. Phone/Fax

Practice location:
  • Phone: 602-362-1823
  • Fax:
Mailing address:
  • Phone: 602-362-1823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL ALEJO
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 480-703-1883