1740232768 NPI number — OB&G PROFESSIONAL LIMITED LIABILITY COMPANY

Table of content: (NPI 1740232768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740232768 NPI number — OB&G PROFESSIONAL LIMITED LIABILITY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OB&G PROFESSIONAL LIMITED LIABILITY COMPANY
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:
OB&G PROFESSIONAL LTD
Provider Other Organization Name Type Code:
3
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:
1740232768
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36680
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85067-6680
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-234-1803
Provider Business Mailing Address Fax Number:
602-234-3748

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W CLARENDON AVE
Provider Second Line Business Practice Location Address:
SUITE 142
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-3449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-234-1803
Provider Business Practice Location Address Fax Number:
602-234-3748
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUSH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
602-234-1803

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 173807 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com