1497824379 NPI number — MARY ANN BOLYOG FNP-C

Table of content: MARY ANN BOLYOG FNP-C (NPI 1497824379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497824379 NPI number — MARY ANN BOLYOG FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLYOG
Provider First Name:
MARY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

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:
1497824379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W UTOPIA RD
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-4171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-214-6148
Provider Business Mailing Address Fax Number:
602-214-6149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6206 W. BELL ROAD
Provider Second Line Business Practice Location Address:
#5
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-375-5440
Provider Business Practice Location Address Fax Number:
602-375-5510
Provider Enumeration Date:
11/07/2006

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: 363LF0000X , with the licence number:  RN017541 , 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: 482538 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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