=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588068134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDER MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2014
-----------------------------------------------------
Last Update Date | 10/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 S VAL VISTA DR STE 188
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-1684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-524-8193
-----------------------------------------------------
Fax | 480-247-4652
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21911 E ESCALANTE RD
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-4589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-524-8193
-----------------------------------------------------
Fax | 480-247-4652
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | ADAM WINTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-577-8836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------