1053338962 NPI number — SOUTHWESTERN ARIZONA NEONATOLOGY PLLC.

Table of content: (NPI 1053338962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053338962 NPI number — SOUTHWESTERN ARIZONA NEONATOLOGY PLLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWESTERN ARIZONA NEONATOLOGY 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:
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:
1053338962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85366-0050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-783-7283
Provider Business Mailing Address Fax Number:
928-783-4257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 S AVENUE A
Provider Second Line Business Practice Location Address:
NICU
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364-7127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-336-7665
Provider Business Practice Location Address Fax Number:
928-336-1559
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WARDA
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
NEONATOLOGY MEDICAL DIRECTOR,SWAN
Authorized Official Telephone Number:
928-336-7665

Provider Taxonomy Codes

  • Taxonomy code: 2080N0001X , with the licence number:  27466 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080N0001X , with the licence number: C50724 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 33879 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 330211 . This is a "AHCCS APIPA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 330211 . This is a "AHCCS MERCYCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 330211 . This is a "AHCCS FFS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ078006 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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