Provider Demographics
NPI:1396917761
Name:L PHILIPP WALL MD PC
Entity type:Organization
Organization Name:L PHILIPP WALL MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LIMOR
Authorized Official - Middle Name:PHILIPP
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-652-3622
Mailing Address - Street 1:PO BOX 29878
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9878
Mailing Address - Country:US
Mailing Address - Phone:623-544-6932
Mailing Address - Fax:623-321-1070
Practice Address - Street 1:15571 N REEMS RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9584
Practice Address - Country:US
Practice Address - Phone:623-544-6932
Practice Address - Fax:623-321-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ120870Medicare PIN