1518953041 NPI number — PETER NIEMCZYK MD

Table of content: PETER NIEMCZYK MD (NPI 1518953041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518953041 NPI number — PETER NIEMCZYK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIEMCZYK
Provider First Name:
PETER
Provider Middle Name:
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:
1518953041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20325 N 51ST AVE
Provider Second Line Business Mailing Address:
#102
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-5674
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-780-2300
Provider Business Mailing Address Fax Number:
623-582-9666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5171 CUB LAKE RD
Provider Second Line Business Practice Location Address:
BLDG C STE 340
Provider Business Practice Location Address City Name:
SHOW LOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85901-7888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-537-0111
Provider Business Practice Location Address Fax Number:
623-582-9666
Provider Enumeration Date:
09/20/2005

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: 208800000X , with the licence number:  34718 , 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: 2Z2716 . This is a "HEALTHNET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 477100 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5135633 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 674661 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00378324 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: AZ0156450 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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