1689813834 NPI number — GERALD J TAITAGUE MD PC

Table of content: (NPI 1689813834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689813834 NPI number — GERALD J TAITAGUE MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERALD J TAITAGUE MD PC
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:
1689813834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 W ROUTE 66
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
WILLIAMS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86046-2567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-635-1044
Provider Business Mailing Address Fax Number:
928-635-1042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 W ROUTE 66
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
WILLIAMS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86046-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-635-1044
Provider Business Practice Location Address Fax Number:
928-635-1042
Provider Enumeration Date:
02/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TAITAGUE
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
928-635-1044

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  26182 , 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: 426503 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 01-0064151 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0865880 . This is a "BLUE CROSS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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