| Shafa Medical Clinic Pc | |
|
202 E Earll Dr Ste 150 Phoenix AZ 85012-2636 | |
| (602) 248-8258 | |
| (602) 248-8259 |
| Full Name | Shafa Medical Clinic Pc |
|---|---|
| Speciality | Clinic/Center |
| Location | 202 E Earll Dr Ste 150, Phoenix, Arizona |
| Authorized Official Name and Position | Amanda Modesta (MEDICAL DIRECTOR /PRESIDENT) |
| Authorized Official Contact | 6022488258 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Shafa Medical Clinic Pc 202 E Earll Dr Ste 150 Phoenix AZ 85012-2636 Ph: (602) 248-8258 | Shafa Medical Clinic Pc 202 E Earll Dr Ste 150 Phoenix AZ 85012-2636 Ph: (602) 248-8258 |
| NPI Number | 1194906925 |
|---|---|
| Provider Enumeration Date | 11/20/2007 |
| Last Update Date | 11/20/2007 |
| Medicare PECOS PAC ID | 3173416641 |
|---|---|
| Medicare Enrollment ID | O20040206000825 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1194906925 | NPI | - | NPPES |
| 447921 | Medicaid | AZ | |
| AZ0860140 | Other | AZ | BC/BS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | 07569335N (Arizona) | Primary |
| Provider Name | Amanda R Modesta Keyhani |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1316993371 PECOS PAC ID: 2062305535 Enrollment ID: I20070208000246 |
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