1104090737 NPI number — JOHN R. MARKHAM PC

Table of content: (NPI 1104090737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104090737 NPI number — JOHN R. MARKHAM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN R. MARKHAM 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:
6
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:
1104090737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1680 WILLOW CREEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-778-3950
Provider Business Mailing Address Fax Number:
928-778-3999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 PALOMINO ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-636-5504
Provider Business Practice Location Address Fax Number:
928-636-0780
Provider Enumeration Date:
04/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MARKHAM
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
928-778-3950

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , 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: 033176 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15220 . This is a "AVESIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0384690001 . This is a "DMERC OPTICAL SUPPLIER - PRESCOTT" identifier . This identifiers is of the category "OTHER".
  • Identifier: AZ01170 . This is a "MEDICARE SUBMITTER ID - PRESCOTT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5858351 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 190721 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 866291-9714 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".




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