Provider Demographics
NPI:1154957678
Name:INFINITY MEDICAL PROVIDERS LLC
Entity type:Organization
Organization Name:INFINITY MEDICAL PROVIDERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREEM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLESKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-699-4066
Mailing Address - Street 1:21001 N TATUM BLVD
Mailing Address - Street 2:STE 1630 BOX 941
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4242
Mailing Address - Country:US
Mailing Address - Phone:602-699-4066
Mailing Address - Fax:480-275-4229
Practice Address - Street 1:350 E EVA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2564
Practice Address - Country:US
Practice Address - Phone:773-410-1676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ004822Medicaid