1245219336 NPI number — DR. BRIAN S PAGE DO

Table of content: DR. BRIAN S PAGE DO (NPI 1245219336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245219336 NPI number — DR. BRIAN S PAGE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAGE
Provider First Name:
BRIAN
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1245219336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20325 N. 51ST AVE.
Provider Second Line Business Mailing Address:
BLD 8 SUITE 160
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-4622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-466-6350
Provider Business Mailing Address Fax Number:
602-358-8698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20325 N. 51ST AVE
Provider Second Line Business Practice Location Address:
BLD 8 SUITE 160
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-466-6350
Provider Business Practice Location Address Fax Number:
602-358-8698
Provider Enumeration Date:
01/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  3416 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 3416 , 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: 461658 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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