1619370426 NPI number — GOOD YEARS FAMILY MEDICINE LLC

Table of content: (NPI 1619370426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619370426 NPI number — GOOD YEARS FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOOD YEARS FAMILY MEDICINE 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:
1619370426
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10240 W INDIAN SCHOOL RD
Provider Second Line Business Mailing Address:
SUITE 155
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85037-5904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-594-3171
Provider Business Mailing Address Fax Number:
623-594-3161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14960 W INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395-7814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-594-3171
Provider Business Practice Location Address Fax Number:
623-594-3161
Provider Enumeration Date:
10/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CHROSTOWSKI
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
623-594-3171

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  31975 , 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)





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