Basic Information
Provider Information | |||||||||
NPI: | 1316276140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UMHAU | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | CHRISTIAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | WHITERIVER | ||||||||
State: | AZ | ||||||||
PostalCode: | 859410860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283383555 | ||||||||
FaxNumber: | 9283385508 | ||||||||
Practice Location | |||||||||
Address1: | 200 WEST HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | WHITERIVER | ||||||||
State: | AZ | ||||||||
PostalCode: | 85941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283383555 | ||||||||
FaxNumber: | 9283385508 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2009 | ||||||||
LastUpdateDate: | 02/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | D28090 | MD | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | HSZ962RBU | 01 |   | WHITERIVER | OTHER | 846790 | 05 | AZ |   | MEDICAID | 020561 | 05 | AZ |   | MEDICAID |