Basic Information
Provider Information | |||||||||
NPI: | 1306832670 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLM | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GODFREY-OLM | ||||||||
OtherFirstName: | PATRICIA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1200 N BEAVER ST | ||||||||
Address2: | PAYER CREDENTIALING | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860013118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282136235 | ||||||||
FaxNumber: | 9282136292 | ||||||||
Practice Location | |||||||||
Address1: | 1050 N SAN FRANCISCO ST | ||||||||
Address2: | STE B | ||||||||
City: | FLAGSTAFF | ||||||||
State: | AZ | ||||||||
PostalCode: | 860013259 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9282143737 | ||||||||
FaxNumber: | 9282143837 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 01/06/2017 | ||||||||
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 | 207R00000X | 22349 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 738093 | 01 |   | HUMANA | OTHER | 809202 | 05 | AZ |   | MEDICAID | AZ0379910 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER |