1164482337 NPI number — EAGLE SPRINGS FAMILY MEDICINE, PLLC

Table of content: (NPI 1164482337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164482337 NPI number — EAGLE SPRINGS FAMILY MEDICINE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE SPRINGS FAMILY MEDICINE, PLLC
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:
1164482337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
903 E. HWY 260
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
PAYSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-468-7700
Provider Business Mailing Address Fax Number:
928-468-7703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 E. HIGHWAY 260,
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PAYSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-468-7700
Provider Business Practice Location Address Fax Number:
928-468-7703
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
928-468-7700

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4333 , 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)





Copyright © 2007-2025 www.npivalidator.com