MEDICARE: SCOTTSDALE INTERNAL MEDICINE PLLC

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
2	364SA2200X	Adult Health Clinical Nurse Specialist

General Provider Information

NPI Number	:	1790050409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTTSDALE INTERNAL MEDICINE PLLC

Provider Business Mailing Address
First Line	:	4643 N 12TH ST STE 101
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-4083
Country	:	US
Telephone Number	:	602-812-3789
Fax Number	:

Provider Business Practice Location Address
First Line	:	4643 N 12TH ST STE 101
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-4083
Country	:	US
Telephone Number	:	602-812-3789
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHARLES BENJAMIN EVANS II
Credential	:	MD
Telephone Number	:	602-292-0552

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	02/29/2024

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