Healthcare Provider Details

I. General information

NPI: 1073647251
Provider Name (Legal Business Name): ELIZABETH E WACK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 W HOSPITAL DR SUITE 175
TUCSON AZ
85704
US

IV. Provider business mailing address

2055 W HOSPITAL DR SUITE 175
TUCSON AZ
85704
US

V. Phone/Fax

Practice location:
  • Phone: 520-575-6944
  • Fax: 520-575-1115
Mailing address:
  • Phone: 520-575-6944
  • Fax: 520-575-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number14736
License Number StateAZ

VIII. Authorized Official

Name: ELIZABETH E WACK
Title or Position: CHAIRMAN OF THE BOARD
Credential: MD
Phone: 520-575-6944