1538354188 NPI number — COPPER BASIN FAMILY MEDICINE PLLC

Table of content: (NPI 1538354188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538354188 NPI number — COPPER BASIN FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPPER BASIN 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:
1538354188
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20185 E OCOTILLO RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
QUEEN CREEK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85242-7663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-888-2010
Provider Business Mailing Address Fax Number:
480-888-2074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20185 E OCOTILLO RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85242-7663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-888-2010
Provider Business Practice Location Address Fax Number:
480-888-2074
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOOSE
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-888-2010

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP2470 , 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: 237244 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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