=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497771471
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL DOUGLAS STANIEC M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5601 W EUGIE AVE SUITE 203
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85304-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-548-1600
-----------------------------------------------------
Fax | 602-548-2470
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42429 N CROSS TIMBERS CT
-----------------------------------------------------
City | ANTHEM
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85086-1098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-551-1097
-----------------------------------------------------
Fax | 602-548-2470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 10600
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------