1003141771 NPI number — PHOENIX RETINA CENTER, LLC

Table of content: (NPI 1003141771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003141771 NPI number — PHOENIX RETINA CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX RETINA CENTER, 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:
1003141771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5410 N SCOTTSDALE RD
Provider Second Line Business Mailing Address:
SUITE A400
Provider Business Mailing Address City Name:
PARADISE VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85253-5927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-278-8980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5410 N SCOTTSDALE RD
Provider Second Line Business Practice Location Address:
SUITE A400
Provider Business Practice Location Address City Name:
PARADISE VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85253-5927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-278-8980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KIRCH
Authorized Official First Name:
INGEBORG
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-278-8980

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  37088 , 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: 69793 . This is a "CHILDRENS MED SEC PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 90546 . This is a "FALLON COMM HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: J28266 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2094514 . This is a "FIRST HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: A37828 . This is a "MEDICARE B" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2098466 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69793 . This is a "HEALTHYSTART" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 784039 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MGMT" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "TRICARE CAMPUS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA15528 . This is a "HARVARD PILGRIM HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0801554 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2098466 . This is a "MEDICAID WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9317749 . This is a "CIGNA HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7241458 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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