MEDICARE: REVOLUTION MEDICAL CENTER, INC

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	261QP2300X	Primary Care Clinic/Center	04836	AZ

General Provider Information

NPI Number	:	1710169180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVOLUTION MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	2015 E CAMELBACK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4710
Country	:	US
Telephone Number	:	602-840-4400
Fax Number	:	602-840-0490

Provider Business Practice Location Address
First Line	:	2015 E CAMELBACK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4710
Country	:	US
Telephone Number	:	602-840-4400
Fax Number	:	602-840-0490

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	DR. JESSE SAGE HAGGARD
Credential	:	N.M.D.
Telephone Number	:	602-463-7177

Provider Enumeration Date	:	11/28/2007
Last Update Date	:	11/28/2007

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