=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598141848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK G. DETTMANN, M.D.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2015
-----------------------------------------------------
Last Update Date | 08/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4801 N 68TH ST
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-481-3076
-----------------------------------------------------
Fax | 480-481-9208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4801 N 68TH ST
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85251-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-481-3076
-----------------------------------------------------
Fax | 480-481-9208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTITIONER
-----------------------------------------------------
Name | DR. FREDERICK GUSTAV DETTMANN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 480-481-3076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1100X
-----------------------------------------------------
Taxonomy Name | Research Clinic/Center
-----------------------------------------------------
License Number | 25333
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------