1588764427 NPI number — PROVIDENCE OF ARIZONA, INC.

Table of content: (NPI 1588764427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588764427 NPI number — PROVIDENCE OF ARIZONA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE OF ARIZONA, INC.
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:
PROVIDENCIA
Provider Other Organization Name Type Code:
5
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:
1588764427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 N CRAYCROFT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85711-1448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-747-6676
Provider Business Mailing Address Fax Number:
520-747-6605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3602 W THOMAS RD
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:
85019-4442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-455-4626
Provider Business Practice Location Address Fax Number:
602-455-4624
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEDGCOCK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
602-455-4626

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  BH-2200 , 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: 796021 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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