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General NPI Number Information
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NPI Number | 1376154625
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Entity Type | Organization
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Legal Business Name | MEMD PROVIDER NETWORK LLC
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Dates
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Enumeration Date | 08/11/2020
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Last Update Date | 09/22/2020
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Provider Practice Location Address
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Address Line | 6910 E CHAUNCEY LN STE 220
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City | PHOENIX
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State | AZ
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Zip | 85054-5162
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Country | US
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Telephone | 480-339-4573
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Fax |
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Provider Business Mailing Address
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Address Line | 6910 E CHAUNCEY LN STE 220
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City | PHOENIX
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State | AZ
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Zip | 85054-5162
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Country | US
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Telephone | 480-339-4573
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | GLENN DEAN
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Credential |
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Telephone | 480-339-4573
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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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