1700889425 NPI number — DR. STEVE M HEILBRUNN MD

Table of content: DR. STEVE M HEILBRUNN MD (NPI 1700889425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700889425 NPI number — DR. STEVE M HEILBRUNN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEILBRUNN
Provider First Name:
STEVE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1700889425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 NORTH BEAVER STREET
Provider Second Line Business Mailing Address:
PAYER CREDENTIALING
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-773-2559
Provider Business Mailing Address Fax Number:
928-213-6292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
294 STATE ROUTE 89A
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
COTTONWOOD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86326-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-634-1331
Provider Business Practice Location Address Fax Number:
928-634-3130
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0011X , with the licence number:  038252E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 49527 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 40553 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X , with the licence number: 40553 , 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: 12188574 . This is a "CAQH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 716542 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91985587 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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