1093789968 NPI number — CLINIC FOR DIGESTIVE DISEASES, PC

Table of content: DR. LISA MODELEVSKY PHARMD (NPI 1518367036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093789968 NPI number — CLINIC FOR DIGESTIVE DISEASES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINIC FOR DIGESTIVE DISEASES, PC
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:
1093789968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13203 N 103RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85351-3099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-972-2116
Provider Business Mailing Address Fax Number:
623-972-0521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13203 N 103RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85351-3099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-972-2116
Provider Business Practice Location Address Fax Number:
623-972-0521
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOTHUR
Authorized Official First Name:
RAMKRISHNA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
623-972-2116

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AZ0805210 . This is a "BCBS OF AZ/DR BETTINGER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 99S007600002 . This is a "SUN HLTH/DR BELLAPRAVALU" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 788036 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250944-02 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268830-02 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0360800 . This is a "BCBS/DR PHELPS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0727350 . This is a "BCBS/DR KOTHUR" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0750990 . This is a "BCBS DR CHOKSHI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 002410-02 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0187530 . This is a "BCBS/DR PATEL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 208604-02 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 855918 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0361810 . This is a "BCBS/DR BELLAPRAVAL" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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