Provider Demographics
NPI:1215119524
Name:PETER NIEMCZYK MD FACS LLC
Entity type:Organization
Organization Name:PETER NIEMCZYK MD FACS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-780-2300
Mailing Address - Street 1:20325 N 51ST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-5674
Mailing Address - Country:US
Mailing Address - Phone:623-780-2300
Mailing Address - Fax:623-583-9666
Practice Address - Street 1:5171 CUB LAKE RD
Practice Address - Street 2:SUITE C340
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7888
Practice Address - Country:US
Practice Address - Phone:928-537-0111
Practice Address - Fax:623-583-9666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34718208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ106974Medicare PIN