Provider Demographics
NPI:1255734919
Name:CUCCHETTI ORTHOPEDICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:CUCCHETTI ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:480-330-3851
Mailing Address - Street 1:4440 N 36TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3588
Mailing Address - Country:US
Mailing Address - Phone:602-952-8111
Mailing Address - Fax:602-952-1572
Practice Address - Street 1:4440 N 36TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3588
Practice Address - Country:US
Practice Address - Phone:602-952-8111
Practice Address - Fax:602-952-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005722207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty