1396729455 NPI number — RICHARD E DONNELLY P.A.-C.

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 1396729455 NPI number — RICHARD E DONNELLY P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DONNELLY
Provider First Name:
RICHARD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
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:
1396729455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 W WHITE MOUNTAIN BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKESIDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85929-7002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-367-4040
Provider Business Mailing Address Fax Number:
928-367-4042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 W. WHITE MOUNTAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85929-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-367-4040
Provider Business Practice Location Address Fax Number:
928-367-4042
Provider Enumeration Date:
12/02/2005

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: 363AS0400X , with the licence number:  1105 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 10186 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 86080015085259A253 . This is a "TRIWEST" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 558930400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 342254 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 970001299 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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