1104449628 NPI number — THE PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC

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 1104449628 NPI number — THE PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
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:
PAIN INSTITUTE OF SOUTHERN ARIZONA
Provider Other Organization Name Type Code:
3
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:
1104449628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4881 E GRANT ROAD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-318-6035
Provider Business Mailing Address Fax Number:
520-829-6661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2241 W 16TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAFFORD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-829-6900
Provider Business Practice Location Address Fax Number:
520-829-6661
Provider Enumeration Date:
05/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
520-829-6776

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 954926 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 526906 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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