1801069158 NPI number — BLACK HILLS UROLOGY GROUP, P.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 1801069158 NPI number — BLACK HILLS UROLOGY GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK HILLS UROLOGY GROUP, P.C.
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:
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:
1801069158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
294 W STATE ROUTE 89A
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
COTTONWOOD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86326-3754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-649-7970
Provider Business Mailing Address Fax Number:
928-649-7971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
294 W STATE ROUTE 89A
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
COTTONWOOD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86326-3754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-649-7970
Provider Business Practice Location Address Fax Number:
928-649-7971
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CAMPENNI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CO.OWNER/PRESIDENT
Authorized Official Telephone Number:
928-649-7970

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  36999 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 4639 , 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: 328233 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4639 . This is a "FOR DR. MICHAEL CAMPENNI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1801069158 . This is a "GROUP NPI FOR BLACK HILLS UROLOGY" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 36999 . This is a "FOR DR. STEVEN KURZWEIL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 324852 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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