1033188909 NPI number — DESERT FOOT SURGEONS P L L C

Table of content: (NPI 1033188909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033188909 NPI number — DESERT FOOT SURGEONS P L L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT FOOT SURGEONS P L L 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:
1033188909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2222 E HIGHLAND AVE
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-4872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-995-1169
Provider Business Mailing Address Fax Number:
602-995-7155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2222 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-995-1169
Provider Business Practice Location Address Fax Number:
602-995-7155
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GELLER
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
602-995-1169

Provider Taxonomy Codes

  • Taxonomy code: 213EP1101X , with the licence number:  0426 , 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: AZ0193430 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: P00057362 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 2Z0674 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 314758 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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