Basic Information
| Provider Information | |||||||||
| NPI: | 1285703918 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLAGSTAFF PRIMARY CARE, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA: FLAGSTAFF PEDIATRIC CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 S YALE ST | ||||||||
| Address2: | STE #252 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287741811 | ||||||||
| FaxNumber: | 9287742006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S YALE ST | ||||||||
| Address2: | STE #252 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287741811 | ||||||||
| FaxNumber: | 9287742006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STUART | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9287741811 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 351282 | 05 | AZ | MEDICAID |