1588603179 NPI number — LAURENCE M SUSINI MD

Table of content: LAURENCE M SUSINI MD (NPI 1588603179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588603179 NPI number — LAURENCE M SUSINI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUSINI
Provider First Name:
LAURENCE
Provider Middle Name:
M
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:
1588603179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 CALLE PORTAL
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
SIERRA VISTA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-458-6088
Provider Business Mailing Address Fax Number:
520-458-3983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 CALLE PORTAL
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
SIERRA VISTA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-458-6088
Provider Business Practice Location Address Fax Number:
520-458-3983
Provider Enumeration Date:
06/06/2006

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: 207X00000X , with the licence number:  17611 , 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: 284985 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0779560 . This is a "BCBS AZ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2Z2281 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".




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