Healthcare Provider Details

I. General information

NPI: 1770961914
Provider Name (Legal Business Name): INTEGRATED PREMIER GROUP SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
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: 480-718-0568
  • Fax: 480-307-6676
Mailing address:
  • Phone: 480-718-0568
  • Fax: 480-307-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number18871
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
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 Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. FERAS ALDAOUD
Title or Position: PROVIDER
Credential: M.D.
Phone: 480-718-0568