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General NPI Number Information
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NPI Number | 1063603470
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Entity Type | Organization
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Legal Business Name | MESA CLINIC OF PHYSICIANS AND SURGEONS, PLLC.
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Dates
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Enumeration Date | 08/09/2007
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Last Update Date | 01/24/2008
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Provider Practice Location Address
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Address Line | 606 N COUNTRY CLUB DR #1
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City | MESA
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State | AZ
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Zip | 85201
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Country | US
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Telephone | 480-969-3511
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Fax | 480-969-0976
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Provider Business Mailing Address
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Address Line | 606 N COUNTRY CLUB DR #1
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City | MESA
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State | AZ
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Zip | 85201
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Country | US
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Telephone | 480-733-4432
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Fax | 480-733-4447
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. SANDRA BAKE
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Credential |
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Telephone | 480-733-4401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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