1093263188 NPI number — PATRIOT INTERNAL MEDICINE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093263188 NPI number — PATRIOT INTERNAL MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRIOT INTERNAL MEDICINE 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:
1093263188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9356 E RITA RD
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85747-6315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-398-7079
Provider Business Mailing Address Fax Number:
520-207-4317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9356 E RITA RD
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85747-6315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-398-7079
Provider Business Practice Location Address Fax Number:
520-207-4317
Provider Enumeration Date:
09/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HENAGER
Authorized Official First Name:
HELENE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-398-7079

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 241716 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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