1427359165 NPI number — BRENDA MOORTHY DO PLLC

Table of content: (NPI 1427359165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427359165 NPI number — BRENDA MOORTHY DO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRENDA MOORTHY DO 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:
COMPREHENSIVE BREAST SURGERY
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:
1427359165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 N 16TH ST
Provider Second Line Business Mailing Address:
STE B232
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-3990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-374-3440
Provider Business Mailing Address Fax Number:
602-374-3441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9179 W THUNDERBIRD RD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-4912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-374-3440
Provider Business Practice Location Address Fax Number:
602-374-3441
Provider Enumeration Date:
11/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOORTHY
Authorized Official First Name:
S
Authorized Official Middle Name:
BRENDA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-374-3440

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4264 , 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: 573751 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".