Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | 5639 | AZ |
NPI | 1467517672 |
---|---|
Provider Name | Dr. Jerry Bains |
First Address | Phoenix, AZ 85016-6512 |
Second Address | Phoenix, AZ 85016-6512 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2006 |
Last Update Date | 08/07/2007 |