Provider Demographics
NPI:1104946771
Name:BELLAIR MEDICAL CLINIC, P.C.
Entity type:Organization
Organization Name:BELLAIR MEDICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:DR
Authorized Official - First Name:AMOR
Authorized Official - Middle Name:C
Authorized Official - Last Name:VILLAREAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-978-4157
Mailing Address - Street 1:17250 N 43RD AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4035
Mailing Address - Country:US
Mailing Address - Phone:602-978-4157
Mailing Address - Fax:602-938-8064
Practice Address - Street 1:17250 N 43RD AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4035
Practice Address - Country:US
Practice Address - Phone:602-978-4157
Practice Address - Fax:602-938-8064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty