MEDICARE: PHAROS DIAGNOSTICS 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	291U00000X	Clinical Medical Laboratory	03D2120595	AZ

General Provider Information

NPI Number	:	1851833768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHAROS DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	3830 VALLEY CENTRE DR
Second Line	:	STE 705 PMB514
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-3307
Country	:	US
Telephone Number	:	520-355-2500
Fax Number	:	855-875-6727

Provider Business Practice Location Address
First Line	:	3814 E 5TH ST
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-5145
Country	:	US
Telephone Number	:	520-355-4500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MR. MICHAEL BERGTHOLD
Credential	:
Telephone Number	:	602-885-3795

Provider Enumeration Date	:	11/08/2016
Last Update Date	:	07/17/2019

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