1063470623 NPI number — LORI-ANN R WILCOX MD

Table of content: LORI-ANN R WILCOX MD (NPI 1063470623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063470623 NPI number — LORI-ANN R WILCOX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILCOX
Provider First Name:
LORI-ANN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREEMAN
Provider Other First Name:
LORI-ANN
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063470623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13943 N 91ST AVE
Provider Second Line Business Mailing Address:
C-101
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85381-3687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-760-9449
Provider Business Mailing Address Fax Number:
623-974-9351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13943 N 91ST AVE
Provider Second Line Business Practice Location Address:
C-101
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-3687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-760-9449
Provider Business Practice Location Address Fax Number:
623-974-9351
Provider Enumeration Date:
05/03/2006

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: 207N00000X , with the licence number:  24876 , 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: 1726808 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 188961600 . This is a "DEPT OF LABOR WORK COMP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0804410 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: WCKLL05 . This is a "MEDICARE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1063470623 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 070010475 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1017047 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z3908 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 99S007000009 . This is a "MEDISUN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 379736 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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