Provider Demographics
NPI:1932608106
Name:STAR CLINIC LLC
Entity type:Organization
Organization Name:STAR CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:YEGANEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-271-8666
Mailing Address - Street 1:PO BOX 72300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-1022
Mailing Address - Country:US
Mailing Address - Phone:623-271-8666
Mailing Address - Fax:623-271-8666
Practice Address - Street 1:14155 N 83RD AVE STE 138
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5652
Practice Address - Country:US
Practice Address - Phone:623-271-8666
Practice Address - Fax:623-271-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38152207VF0040X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ335672Medicaid