1386963841 NPI number — TOEDR1 LLC

Table of content: (NPI 1386963841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386963841 NPI number — TOEDR1 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOEDR1 LLC
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:
M BARRY ROSENTHAL DPM
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:
1386963841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6516 N VIA DIVINA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85750-0970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-299-9499
Provider Business Mailing Address Fax Number:
520-299-6571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6548 E CARONDELET DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85710-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-293-6000
Provider Business Practice Location Address Fax Number:
520-299-6571
Provider Enumeration Date:
05/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROSENTHAL
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
BARRY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-299-9499

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  AR8108703 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TOEDR . This is a "TRICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 700593 05 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1Z1517 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0191700 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".