=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548779986
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA PRIMARY CARE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2017
-----------------------------------------------------
Last Update Date | 12/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4111 E VALLEY AUTO DR
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85206-4605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-982-0922
-----------------------------------------------------
Fax | 480-539-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3117 E HOBART ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-9175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-982-0922
-----------------------------------------------------
Fax | 480-539-2888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | CHELSEA ROBERTS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-982-0922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 51986
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 51986
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------