=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174514756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR FAMILY PHYSICIAN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2005
-----------------------------------------------------
Last Update Date | 11/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20860 N TATUM BLVD STE 300
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85050-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-833-4686
-----------------------------------------------------
Fax | 602-666-4686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1920 E BELL RD UNIT 1156
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85022-6290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-833-4686
-----------------------------------------------------
Fax | 602-666-4646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KARLA L BIRKHOLZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 602-833-4686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 13789
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------