MEDICARE: TRI-CITY EXPRESS CARE, PLLC

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	261QU0200X	Urgent Care Clinic/Center	OTC5286	AZ
2	208D00000X	General Practice Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTC5286	OTHER	AZ	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104196302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-CITY EXPRESS CARE, PLLC

Provider Business Mailing Address
First Line	:	890 W ELLIOT RD
Second Line	:	SUITE 103
City	:	GILBERT
State	:	AZ
Zip	:	85233-5102
Country	:	US
Telephone Number	:	480-545-2787
Fax Number	:	480-545-1413

Provider Business Practice Location Address
First Line	:	7850 N SILVERBELL RD
Second Line	:	SUITE 132
City	:	TUCSON
State	:	AZ
Zip	:	85743-8219
Country	:	US
Telephone Number	:	520-407-5884
Fax Number	:	520-744-6556

Authorized Official
Title or Position	:	CMO
Name	:	MICHAEL DUNN
Credential	:	MD
Telephone Number	:	480-545-2787

Provider Enumeration Date	:	01/04/2012
Last Update Date	:	05/23/2013

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