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6390 E Broadway Blvd Tucson AZ 85710-3517 | |
| (520) 284-7949 | |
| (520) 448-9799 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 6390 E Broadway Blvd, Tucson, Arizona |
| Authorized Official Name and Position | Susana M Rodriguez (SENIOR MANAGING PARTNER) |
| Authorized Official Contact | 5202482432 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
6390 E Broadway Blvd Tucson AZ 85710-3517 Ph: (520) 388-0155 | 6390 E Broadway Blvd Tucson AZ 85710-3517 Ph: (520) 284-7949 |
| NPI Number | 1023614609 |
|---|---|
| Provider Enumeration Date | 12/08/2020 |
| Last Update Date | 03/20/2024 |
| Certification Date | 03/20/2024 |
| Medicare PECOS PAC ID | 4587071493 |
|---|---|
| Medicare Enrollment ID | O20210320000050 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023614609 | NPI | - | NPPES |
| Provider Name | Carl F Diener |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1558461152 PECOS PAC ID: 7810922820 Enrollment ID: I20050928001062 |
| Provider Name | Anthony I Fernandez |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1023181377 PECOS PAC ID: 9739283292 Enrollment ID: I20070323000020 |
| Provider Name | Michael Keith Elder |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1295304731 PECOS PAC ID: 1850793803 Enrollment ID: I20210713002443 |
| Provider Name | Stephanie A Shepherd |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1962161216 PECOS PAC ID: 1052703493 Enrollment ID: I20220117000645 |
| Provider Name | Judy V Brevaire |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1669612388 PECOS PAC ID: 2466894969 Enrollment ID: I20240530000005 |
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