Basic Information
| Provider Information | |||||||||
| NPI: | 1154746865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COPPER STATE HOSPITAL AND SURGICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40760 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852740760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2852 S CARRIAGE LN | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852027801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807069430 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | HERZOG | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4807069430 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5596 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.