=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871875047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ OBSTETRICS & GYNECOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 S DOBSON RD SUITE 316
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85202-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-835-1716
-----------------------------------------------------
Fax | 480-290-7094
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 S DOBSON RD SUITE 316
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85202-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-835-1716
-----------------------------------------------------
Fax | 480-290-7094
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | JENNIFER A TUMLINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-789-1189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 32889
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------