MEDICARE: PHOENIX WEST INTERNAL MEDICINE 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	207R00000X	Internal Medicine Physician	30062	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609805530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX WEST INTERNAL MEDICINE LLC

Provider Business Mailing Address
First Line	:	9524 W CAMELBACK RD
Second Line	:	STE 130 PMB186
City	:	GLENDALE
State	:	AZ
Zip	:	85305-3104
Country	:	US
Telephone Number	:	623-322-1145
Fax Number	:	623-466-9552

Provider Business Practice Location Address
First Line	:	4150 N 108TH AVE
Second Line	:	STE 142
City	:	PHOENIX
State	:	AZ
Zip	:	85037-5467
Country	:	US
Telephone Number	:	623-322-1145
Fax Number	:	623-466-9552

Authorized Official
Title or Position	:	OWNER
Name	:	FERNANDO RAUL DE CASTRO
Credential	:	M.D.
Telephone Number	:	623-322-1145

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	03/08/2011

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Directions to “PHOENIX WEST INTERNAL MEDICINE LLC ” Practice Location

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