1972689412 NPI number — CRITERION MEDICAL CORPORATION

Table of content: (NPI 1972689412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972689412 NPI number — CRITERION MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRITERION MEDICAL CORPORATION
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:
1972689412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3632 E SOUTH FORK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85044-6614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-608-9491
Provider Business Mailing Address Fax Number:
480-706-6582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3632 E SOUTH FORK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85044-6614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-608-9491
Provider Business Practice Location Address Fax Number:
480-706-6582
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-608-9491

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D4317790001 . This is a "UNITED AMERICAN INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41730200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com