1164425096 NPI number — GREGORY MERRILL KOSHKARIAN MD

Table of content: KELLY LEONARD (NPI 1851926810)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164425096 NPI number — GREGORY MERRILL KOSHKARIAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOSHKARIAN
Provider First Name:
GREGORY
Provider Middle Name:
MERRILL
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:
1164425096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3709 N CAMPBELL AVE
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85719-1563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-838-3540
Provider Business Mailing Address Fax Number:
520-325-3526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6080 N LA CHOLLA BLVD # 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85741-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-797-8550
Provider Business Practice Location Address Fax Number:
520-797-6986
Provider Enumeration Date:
05/24/2005

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:  24327 , 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: 1033508 . This is a "FIRST HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 10055687 . This is a "PPO NEXT" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1Z3634 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 351057 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: XPY196923 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102612 . This is a "PREFERRED HEALTH NETWORK" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 5073466 . This is a "CCN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 0143348 . This is a "STATE OF WA DEPT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 100666 . This is a "ONE HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0860310 . This is a "BCBS OF ARIZONA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 060057126 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1172298 00 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5132491 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 005502491 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2198525 . This is a "GHI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 25-00275 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 8274243 . This is a "STATE OF WA HLTH & SOC SR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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