Basic Information
Provider Information | |||||||||
NPI: | 1215925821 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACCOLLUM | ||||||||
FirstName: | BARBARA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLER | ||||||||
OtherFirstName: | BARBARA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3020 E CAMELBACK RD | ||||||||
Address2: | SUITE 301 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850165059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022649100 | ||||||||
FaxNumber: | 6022649101 | ||||||||
Practice Location | |||||||||
Address1: | 1300 N 12TH ST | ||||||||
Address2: | SUITE 613 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850062848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6022545321 | ||||||||
FaxNumber: | 6022546582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2005 | ||||||||
LastUpdateDate: | 02/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 15579 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 317047 | 01 | AZ | MEDICAID GROUP NUMBER | OTHER | 120390 | 01 | AZ | MEDICARE GROUP NUMBER | OTHER | 260240 | 05 | AZ |   | MEDICAID |