Basic Information
Provider Information | |||||||||
NPI: | 1124203856 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VERDE VALLEY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VERDE VALLEY MEDICAL CENTER ANESTHESIA DEPARTMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 N BEAVER ST | ||||||||
Address2: | ATTN: MANAGED CARE CONTRACTING | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860013118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282136543 | ||||||||
FaxNumber: | 9282143613 | ||||||||
Practice Location | |||||||||
Address1: | 269 S CANDY LN | ||||||||
Address2: |   | ||||||||
City: | COTTONWOOD | ||||||||
State: | AZ | ||||||||
PostalCode: | 863264158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9287732546 | ||||||||
FaxNumber: | 9282136292 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/31/2007 | ||||||||
LastUpdateDate: | 04/15/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAASE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | NAH CHIEF SYSTEMS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9287732059 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VERDE VALLEY MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | H-122 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.