1568455384 NPI number — KEVAN A PICKREL MD

Table of content: KEVAN A PICKREL MD (NPI 1568455384)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568455384 NPI number — KEVAN A PICKREL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKREL
Provider First Name:
KEVAN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1568455384
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9225 N 3RD ST
Provider Second Line Business Mailing Address:
STE 304
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85020-2439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-445-0751
Provider Business Mailing Address Fax Number:
602-424-8128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9225 N 3RD ST
Provider Second Line Business Practice Location Address:
STE 304
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85020-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-445-0751
Provider Business Practice Location Address Fax Number:
602-424-8128
Provider Enumeration Date:
08/26/2005

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: 207R00000X , with the licence number:  30069 , 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: 715550 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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