MEDICARE: ARIZONA ALLERGY AND ASTHMA SPECIALISTS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207K00000X	Allergy & Immunology Physician	21604	AZ

General Provider Information

NPI Number	:	1083111603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA ALLERGY AND ASTHMA SPECIALISTS PC

Provider Business Mailing Address
First Line	:	16611 S 40TH ST STE 170
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0565
Country	:	US
Telephone Number	:	480-705-8844
Fax Number	:	480-705-8838

Provider Business Practice Location Address
First Line	:	16611 S 40TH ST STE 170
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-0565
Country	:	US
Telephone Number	:	480-705-8844
Fax Number	:	480-705-8838

Authorized Official
Title or Position	:	MD
Name	:	MR. BRIAN WADE MILLHOLLON
Credential	:	MD
Telephone Number	:	480-705-8844

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	04/10/2018

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