Provider Demographics
NPI:1174514756
Name:YOUR FAMILY PHYSICIAN PC
Entity type:Organization
Organization Name:YOUR FAMILY PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRKHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-833-4686
Mailing Address - Street 1:1920 E BELL RD UNIT 1156
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-6290
Mailing Address - Country:US
Mailing Address - Phone:602-833-4686
Mailing Address - Fax:602-666-4646
Practice Address - Street 1:20860 N TATUM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4283
Practice Address - Country:US
Practice Address - Phone:602-833-4686
Practice Address - Fax:602-666-4686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13789OtherLICENSE NUMBER
AZ22506Medicare PIN
AZ13789OtherLICENSE NUMBER