=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801161658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RELIABLE SPECIALTY PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2012
-----------------------------------------------------
Last Update Date | 03/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6929 N HAYDEN RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85250-7978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-404-4423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4315 COMMERCE DR 440-222
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47905-3822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-404-4423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | UCHENDU AZODO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 765-404-4423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 41847
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------