1972898013 NPI number — ROBERT J CASEY DO PC

Table of content: (NPI 1972898013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972898013 NPI number — ROBERT J CASEY DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERT J CASEY DO 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:
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:
1972898013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2930
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINETOP
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85935-2930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-532-1220
Provider Business Mailing Address Fax Number:
928-532-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5171 CUB LAKE RD STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOW LOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85901-7888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-532-1220
Provider Business Practice Location Address Fax Number:
928-532-1222
Provider Enumeration Date:
06/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CASEY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-532-1220

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  1955 , 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: 239683 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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