1558654517 NPI number — WEST VALLEY PHYSICIAN GROUP LLC

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 1558654517 NPI number — WEST VALLEY PHYSICIAN GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST VALLEY PHYSICIAN GROUP LLC
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:
1558654517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5115 N DYSART RD
Provider Second Line Business Mailing Address:
SUITE 202 #611
Provider Business Mailing Address City Name:
LITCHFIELD PARK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85340-3032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-547-5385
Provider Business Mailing Address Fax Number:
623-547-5386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7710 W LOWER BUCKEYE RD
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85043-3439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-776-2225
Provider Business Practice Location Address Fax Number:
623-776-2299
Provider Enumeration Date:
05/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MAHER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
623-547-5385

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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