MEDICARE: ARIZONA SKIN AND DERMATOLOGY 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	207Q00000X	Family Medicine Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1558767962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARIZONA SKIN AND DERMATOLOGY PC

Provider Business Mailing Address
First Line	:	PO BOX 5002
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85385-5002
Country	:	US
Telephone Number	:	623-815-8200
Fax Number	:	623-344-5458

Provider Business Practice Location Address
First Line	:	10249 W THUNDERBIRD BLVD
Second Line	:	SUIT 100
City	:	SUN CITY
State	:	AZ
Zip	:	85351-3113
Country	:	US
Telephone Number	:	623-815-8200
Fax Number	:	623-344-5458

Authorized Official
Title or Position	:	OWNER
Name	:	MANNTEJ SRA
Credential	:	M.D.
Telephone Number	:	623-815-8200

Provider Enumeration Date	:	11/12/2014
Last Update Date	:	11/12/2014

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