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General NPI Number Information
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NPI Number | 1033622626
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Entity Type | Organization
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Legal Business Name | AGAVE MEDICAL GROUP PLLC
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Dates
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Enumeration Date | 11/06/2017
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Last Update Date | 11/06/2017
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Provider Practice Location Address
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Address Line | 1301 S. CRIMAON RD
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City | MESA
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State | AZ
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Zip | 85209-2737
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Country | US
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Telephone | 480-219-6631
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Fax | 480-247-3251
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Provider Business Mailing Address
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Address Line | 2925 EAST RIGGS RD SUITE 8 PMB 179
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City | CHANDLER
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State | AZ
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Zip | 85249-3600
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Country | US
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Telephone | 480-219-6631
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Fax | 480-247-3251
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Authorized Official
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Title or Position | OWNER
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Name | RALPH A DISILVA
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Credential | M.D.
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Telephone | 480-219-6631
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208M00000X
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Taxonomy Name | Hospitalist Physician
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License Number | 36884
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License Number State | AZ
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