1992061162 NPI number — ARIZONA DERMATOLOGY SPECIALISTS, PLLC

Table of content: (NPI 1992061162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992061162 NPI number — ARIZONA DERMATOLOGY SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARIZONA DERMATOLOGY SPECIALISTS, PLLC
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:
1992061162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 9290
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85374-9290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-584-3376
Provider Business Mailing Address Fax Number:
623-584-3375

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14800 W. MOUNTAIN VIEW BLVD.
Provider Second Line Business Practice Location Address:
STE. 160
Provider Business Practice Location Address City Name:
SURPRISE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85374-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-584-3376
Provider Business Practice Location Address Fax Number:
623-584-3375
Provider Enumeration Date:
04/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BARLOW
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
602-793-8411

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X , with the licence number:  29708 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 29708 , 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: 721358 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P17495542 . This is a "AZ PLLC REGISTRATION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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