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NPI Code Detail

MEDICARE: PROVIDENCE GENERAL MEDICINE, PC

MEDICARE: PROVIDENCE GENERAL MEDICINE, 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
1207R00000XInternal Medicine Physician31836AZ

General Provider Information

NPI Number : 1164693974
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENCE GENERAL MEDICINE, PC
Provider Business Mailing Address
First Line : 9220 N. CENTRAL AVENUE
Second Line :
City : PHOENIX
State : AZ
Zip : 85020-2416
Country : US
Telephone Number : 602-254-7077
Fax Number : 602-254-7078
Provider Business Practice Location Address
First Line : 9220 N. CENTRAL AVENUE
Second Line :
City : PHOENIX
State : AZ
Zip : 85020-2416
Country : US
Telephone Number : 602-254-7077
Fax Number : 602-254-7078
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : DR. GERARDO SICALO OBORSKY
Credential : M.D.
Telephone Number : 602-254-7077
Provider Enumeration Date : 03/19/2008
Last Update Date : 09/27/2011

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Directions to “PROVIDENCE GENERAL MEDICINE, PC ” Practice Location

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