Healthcare Provider Details

I. General information

NPI: 1073569182
Provider Name (Legal Business Name): EAST VALLEY ORTHOPEDIC AND SPINE ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 S MILL AVE 1492 S MILL AVE #212
TEMPE AZ
85281-5652
US

IV. Provider business mailing address

1492 S MILL AVE 1492 S MILL AVE #212
TEMPE AZ
85281-5664
US

V. Phone/Fax

Practice location:
  • Phone: 480-449-3867
  • Fax: 480-449-3868
Mailing address:
  • Phone: 480-449-3867
  • Fax: 480-449-3868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number3893
License Number StateAZ

VIII. Authorized Official

Name: MS. KAREN A BLACK
Title or Position: MANAGAER
Credential:
Phone: 480-449-2401