1104196302 NPI number — TRI-CITY EXPRESS CARE, PLLC

Table of content: (NPI 1104196302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104196302 NPI number — TRI-CITY EXPRESS CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-CITY EXPRESS CARE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FASTMED URGENT CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104196302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
890 W ELLIOT RD
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85233-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-545-2787
Provider Business Mailing Address Fax Number:
480-545-1413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7850 N SILVERBELL RD
Provider Second Line Business Practice Location Address:
SUITE 132
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85743-8219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-407-5884
Provider Business Practice Location Address Fax Number:
520-744-6556
Provider Enumeration Date:
01/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DUNN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
480-545-2787

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: OTC5286 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OTC5286 . This is a "STATE LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 679506 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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