1942607445 NPI number — FORTY THIRD MEDICAL ASSOCIATES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942607445 NPI number — FORTY THIRD MEDICAL ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORTY THIRD MEDICAL ASSOCIATES, 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:
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:
1942607445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7725 N 43RD AVE
Provider Second Line Business Mailing Address:
# 111
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85051-5770
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-931-9201
Provider Business Mailing Address Fax Number:
623-934-5414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7725 N 43RD AVE
Provider Second Line Business Practice Location Address:
# 111
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85051-5770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-931-9201
Provider Business Practice Location Address Fax Number:
623-934-5414
Provider Enumeration Date:
11/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MCCUE
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
719-761-1985

Provider Taxonomy Codes

  • Taxonomy code: 246XC2903X , with the licence number:  98313 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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