Basic Information
| Provider Information | |||||||||
| NPI: | 1073609848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN C LINCOLN LLC | ||||||||
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| OtherOrganizationName: | PINNACLE ANTHEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234346200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3648 W ANTHEM WAY | ||||||||
| Address2: | SUITE A100 | ||||||||
| City: | ANTHEM | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024857482 | ||||||||
| FaxNumber: | 6234346448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANSPACH | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. VP | ||||||||
| AuthorizedOfficialTelephone: | 6234346200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | OTC3148 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 207Q00000X | OTC 3490 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.