=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003955832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA FAMILY PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 E BASELINE RD 104
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-897-7070
-----------------------------------------------------
Fax | 480-897-2597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2127 E BASELINE RD 104
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-1537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-897-7070
-----------------------------------------------------
Fax | 480-897-2597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREGORY LEE ELLISON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 480-897-7070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD12426
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------