MEDICARE: ALLIANCE MEDICAL CLINIC, 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	363LF0000X	Family Nurse Practitioner
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1740224054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIANCE MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	42104 N VENTURE DR
Second Line	:	SUITE D 118
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:	623-505-6565
Fax Number	:	623-505-6565

Provider Business Practice Location Address
First Line	:	42104 N VENTURE DR
Second Line	:	SUITE D118
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3823
Country	:	US
Telephone Number	:	623-505-6565
Fax Number	:	623-551-5567

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ALICIA ANNE BAER
Credential	:
Telephone Number	:	623-271-8704

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	04/12/2022

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