MEDICARE: B--UMCP SUPER SPECIALISTS LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1518311695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	B--UMCP SUPER SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	2901 N CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 N 12TH ST STE 404
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-2866
Country	:	US
Telephone Number	:	602-839-7000
Fax Number	:

Authorized Official
Title or Position	:	SR VP FINANCE
Name	:	DENNIS DAHLEN
Credential	:
Telephone Number	:	602-747-4000

Provider Enumeration Date	:	04/14/2016
Last Update Date	:	04/14/2016

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