1285687822 NPI number — PHOENIX NEUROLOGY AND SLEEP MEDICINE PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285687822 NPI number — PHOENIX NEUROLOGY AND SLEEP MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX NEUROLOGY AND SLEEP 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:
1285687822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 205112
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-5112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-535-0050
Provider Business Mailing Address Fax Number:
623-535-9620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2940 N LITCHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395-7830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-535-0050
Provider Business Practice Location Address Fax Number:
623-535-9620
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
TROY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
623-535-0050

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 918581 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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