MEDICARE: COTTONWOOD PHYSICIAN GROUP

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1700408689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTONWOOD PHYSICIAN GROUP

Provider Business Mailing Address
First Line	:	PO BOX 964
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85299-0964
Country	:	US
Telephone Number	:	480-366-4489
Fax Number	:	602-635-3683

Provider Business Practice Location Address
First Line	:	1760 E VILLA DR STE E&F
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326-4679
Country	:	US
Telephone Number	:	480-366-4489
Fax Number	:	602-635-3683

Authorized Official
Title or Position	:	CEO
Name	:	JEREMIAH FABER
Credential	:
Telephone Number	:	480-258-3635

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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