1063413177 NPI number — WARREN MARK BREISBLATT MD

Table of content: WARREN MARK BREISBLATT MD (NPI 1063413177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063413177 NPI number — WARREN MARK BREISBLATT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREISBLATT
Provider First Name:
WARREN
Provider Middle Name:
MARK
Provider Name Prefix Text:
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:
1063413177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W UTOPIA RD
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-214-6148
Provider Business Mailing Address Fax Number:
602-214-6149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9250 N. 3RD STREET
Provider Second Line Business Practice Location Address:
SUITE 3010
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85020-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-861-1168
Provider Business Practice Location Address Fax Number:
602-861-1763
Provider Enumeration Date:
08/10/2005

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: 207RC0000X , with the licence number:  24667 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: 24667 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207UN0901X , with the licence number: 24667 , 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: 370247 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".