MEDICARE: PARADISE VALLEY ALLERGY ASSOC LTD

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	2080P0201X	Pediatric Allergy/Immunology Physician	11856	AZ
2	207KA0200X	Allergy Physician	11856	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4022160	OTHER	AZ	AETNA PPO
2	0200027	OTHER	AZ	UNITED HEATH CARE
3	1Z2992	OTHER	AZ	HEALTHNET
4	2572627	OTHER	AZ	AETNA HMO
5	AZ0027920	OTHER	AZ	BCBS

General Provider Information

NPI Number	:	1356414346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADISE VALLEY ALLERGY ASSOC LTD

Provider Business Mailing Address
First Line	:	20940 N TATUM BLVD
Second Line	:	STE 205
City	:	PHOENIX
State	:	AZ
Zip	:	85050-7260
Country	:	US
Telephone Number	:	480-991-1930
Fax Number	:	480-443-8196

Provider Business Practice Location Address
First Line	:	20940 N TATUM BLVD
Second Line	:	STE 205
City	:	PHOENIX
State	:	AZ
Zip	:	85050-7260
Country	:	US
Telephone Number	:	480-991-1930
Fax Number	:	480-443-8196

Authorized Official
Title or Position	:	CEO
Name	:	DR. RICHARD GEORGE KEIGHTLEY
Credential	:	MD
Telephone Number	:	480-991-1930

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	03/14/2012

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Directions to “PARADISE VALLEY ALLERGY ASSOC LTD ” Practice Location

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