1235309360 NPI number — IZZY PAIN MANGEMENT P C

Table of content: (NPI 1235309360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235309360 NPI number — IZZY PAIN MANGEMENT P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IZZY PAIN MANGEMENT P C
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:
1235309360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44047 N 43RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85087-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-595-2986
Provider Business Mailing Address Fax Number:
602-595-3041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8910 N 43RD AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85302-5340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-595-2986
Provider Business Practice Location Address Fax Number:
602-595-3041
Provider Enumeration Date:
03/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
IZUEGBUNAM
Authorized Official First Name:
EDITH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
602-595-2986

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  31461 , 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: 793837 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 331102 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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