=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477222669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P&G FAMILY PRACTICE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2021
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1653 E MCMURRAY BLVD STE 144A
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85122-5934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-883-3011
-----------------------------------------------------
Fax | 480-802-3874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 171 W CENTRAL AVE
-----------------------------------------------------
City | COOLIDGE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85128-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-723-7726
-----------------------------------------------------
Fax | 520-723-4513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHETAN PATEL
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 520-723-7726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------