1164776845 NPI number — CAMELBACK MOUNTAIN MEDICAL ASSOCIATES PC

Table of content: WILL CLARK COWAN III CRNA (NPI 1952589749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164776845 NPI number — CAMELBACK MOUNTAIN MEDICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMELBACK MOUNTAIN MEDICAL ASSOCIATES 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:
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:
1164776845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 E MONTEREY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85012-2618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-266-4383
Provider Business Mailing Address Fax Number:
602-266-4384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E MONTEREY WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85012-2618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-266-4383
Provider Business Practice Location Address Fax Number:
602-266-4384
Provider Enumeration Date:
11/02/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CIPOLLA
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
GRIFFIN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
602-266-4383

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2811 , 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: 341769 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".