=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770023129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE AMBULATORY HEALTHCARE L.L.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2017
-----------------------------------------------------
Last Update Date | 03/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18362 N 94TH PL
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-451-5492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18362 N 94TH PL
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-451-5492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SERVICE REPRESENTATIVE
-----------------------------------------------------
Name | SHAVAWN PERSCHKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-451-5492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 44077
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------