1659402998 NPI number — EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC

Table of content: (NPI 1659402998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659402998 NPI number — EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VALLEY SPINE AND SPORTS MEDICINE CENTER, PLC
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:
6
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:
1659402998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4858 E BASELINE RD STE 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85206-4638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-807-6500
Provider Business Mailing Address Fax Number:
866-835-7591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4858 E BASELINE RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85206-4638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-807-6500
Provider Business Practice Location Address Fax Number:
866-835-7591
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAPPOE
Authorized Official First Name:
TUTANKHAMEN
Authorized Official Middle Name:
ALLOTEY
Authorized Official Title or Position:
OWNER AND PHYSICIAN
Authorized Official Telephone Number:
480-807-6500

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  33084 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081S0010X , with the licence number: 33084 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 873671 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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