1356570378 NPI number — ARIZONA CLINIC OF GASTROENTEROLOGY 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 1356570378 NPI number — ARIZONA CLINIC OF GASTROENTEROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA CLINIC OF GASTROENTEROLOGY 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:
1356570378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85385-5819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-283-4714
Provider Business Mailing Address Fax Number:
623-444-5495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13934 N 59TH AVE
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85306-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-283-4714
Provider Business Practice Location Address Fax Number:
623-444-5495
Provider Enumeration Date:
07/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PEIRSON
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
877-283-4714

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  31649 , 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: 469524 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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