Provider Demographics
NPI:1164836169
Name:ADAMANTIUM INK P.A.
Entity type:Organization
Organization Name:ADAMANTIUM INK P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARASIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-791-4931
Mailing Address - Street 1:8424 E SHEA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3954 E WALLER LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4916
Practice Address - Country:US
Practice Address - Phone:713-791-4931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-17
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMD47798310400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty