1609805530 NPI number — PHOENIX WEST INTERNAL MEDICINE LLC

Table of content: (NPI 1609805530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609805530 NPI number — PHOENIX WEST INTERNAL MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX WEST INTERNAL MEDICINE 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:
Provider Other Organization Name Type Code:
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:
1609805530
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9524 W CAMELBACK RD
Provider Second Line Business Mailing Address:
STE 130 PMB186
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85305-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-322-1145
Provider Business Mailing Address Fax Number:
623-466-9552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4150 N 108TH AVE
Provider Second Line Business Practice Location Address:
STE 142
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85037-5467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-322-1145
Provider Business Practice Location Address Fax Number:
623-466-9552
Provider Enumeration Date:
07/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DE CASTRO
Authorized Official First Name:
FERNANDO
Authorized Official Middle Name:
RAUL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
623-322-1145

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  30062 , 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: 648735 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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