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General NPI Number Information
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NPI Number | 1144206541
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Entity Type | Organization
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Legal Business Name | HOMEWOOD FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 12/16/2005
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Last Update Date | 10/18/2007
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Provider Practice Location Address
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Address Line | 4540 E BASELINE RD #113
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City | MESA
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State | AZ
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Zip | 85206-4613
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Country | US
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Telephone | 480-558-4700
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Fax | 480-558-1936
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Provider Business Mailing Address
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Address Line | PO BOX 1927
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City | GILBERT
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State | AZ
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Zip | 85299-1927
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Country | US
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Telephone | 480-558-4700
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Fax | 480-558-1936
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Authorized Official
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Title or Position | OWNER
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Name | RUSSELL JAY HOMEWOOD
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Credential | DO
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Telephone | 480-558-4700
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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 | 3268
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License Number State | AZ
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