=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043591795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESS CARE MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 07/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3219 E CAMELBACK RD SUITE 545
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-820-0026
-----------------------------------------------------
Fax | 602-288-6500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3219 E CAMELBACK RD SUITE 545
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-820-0026
-----------------------------------------------------
Fax | 602-288-6500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | TODD DREITZLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 602-820-0026
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------