1003141771 NPI number — PHOENIX RETINA CENTER, LLC

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 1003141771 NPI number — PHOENIX RETINA CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX RETINA CENTER, LLC
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:
1003141771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5410 N SCOTTSDALE RD
Provider Second Line Business Mailing Address:
SUITE A400
Provider Business Mailing Address City Name:
PARADISE VALLEY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85253-5927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-278-8980
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5410 N SCOTTSDALE RD
Provider Second Line Business Practice Location Address:
SUITE A400
Provider Business Practice Location Address City Name:
PARADISE VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85253-5927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-278-8980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KIRCH
Authorized Official First Name:
INGEBORG
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-278-8980

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  37088 , 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: 69793 . This is a "CHILDRENS MED SEC PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 90546 . This is a "FALLON COMM HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: J28266 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2094514 . This is a "FIRST HEALTH" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: A37828 . This is a "MEDICARE B" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2098466 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 69793 . This is a "HEALTHYSTART" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 784039 . This is a "MVP HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "HEALTHCARE VALUE MGMT" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "TRICARE CAMPUS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "ONE HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA15528 . This is a "HARVARD PILGRIM HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "THREE RIVERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0801554 . This is a "EVERCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2098466 . This is a "MEDICAID WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9317749 . This is a "CIGNA HEALTH PLAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 042472266 . This is a "PRIVATE HEALTHCARE SYSTEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7241458 . This is a "AETNA US HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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