1861617938 NPI number — MRS. SUSAN ELLEN DAVIS EDS

Table of content: MRS. SUSAN ELLEN DAVIS EDS (NPI 1861617938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861617938 NPI number — MRS. SUSAN ELLEN DAVIS EDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
SUSAN
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
EDS
Provider Gender Code:
F

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:
1861617938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 N COUNTRY CLUB DR
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:
85201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-472-0727
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 W 8TH ST
Provider Second Line Business Practice Location Address:
MESA PUBLIC SCHOOLS WESTWOOD HIGH SCHOOL
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-3999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-472-4400
Provider Business Practice Location Address Fax Number:
480-472-4509
Provider Enumeration Date:
04/16/2007

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: 103TS0200X , 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: 636970 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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