1104930130 NPI number — DOWNRIVER MENTAL HEALTH CLINIC PC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104930130 NPI number — DOWNRIVER MENTAL HEALTH CLINIC PC

Employer Identification Number (EIN):

Provider Organization Name:

DOWNRIVER MENTAL HEALTH CLINIC 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 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:

1104930130

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

03/01/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

4800 N SCOTTSDALE RD STE 2500

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SCOTTSDALE

Provider Business Mailing Address State Name:

AZ

Provider Business Mailing Address Postal Code:

85251-7630

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

480-524-0990

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

20500 EUREKA RD

Provider Second Line Business Practice Location Address:

SUITE 200

Provider Business Practice Location Address City Name:

TAYLOR

Provider Business Practice Location Address State Name:

MI

Provider Business Practice Location Address Postal Code:

48180-6394

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

734-285-8282

Provider Business Practice Location Address Fax Number:

734-281-0402

Provider Enumeration Date:

08/18/2006

Authorized Official Last Name:

PARDO

Authorized Official First Name:

RYAN

Authorized Official Middle Name:

Authorized Official Title or Position:

CHIEF LEGAL OFFICER

Authorized Official Telephone Number:

206-399-1493

• Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 003433000 188713000 . This is a "MAGELLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 4441363 . This is a "TEAMSTERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 7509106200 . This is a "BCBS OF MI:MENTAL HEALTH" identifier . This identifiers is of the category "OTHER".
• Identifier: BM820042 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 004241F3 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 101039 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
• Identifier: 511213 . This is a "CARE CHOICES" identifier . This identifiers is of the category "OTHER".
• Identifier: 4449395 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".