1063476042 NPI number — DR. ANDREW JOSEPH SASSACK III M.D.

Table of content: DR. ANDREW JOSEPH SASSACK III M.D. (NPI 1063476042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063476042 NPI number — DR. ANDREW JOSEPH SASSACK III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SASSACK
Provider First Name:
ANDREW
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1063476042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKYLAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28776-2425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2644
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 E TANGERINE RD
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
ORO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85755-6225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-326-1266
Provider Business Practice Location Address Fax Number:
520-326-2575
Provider Enumeration Date:
04/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  49772 , 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: Z173338 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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