Basic Information
| Provider Information | |||||||||
| NPI: | 1427335140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS IHS PHOENIX AREA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WHITERIVER INDIAN HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
| Address2: | P.O. BOX 860 | ||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 WEST HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283385508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 11/27/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9283384911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 092403 | 01 | AZ | MEDICAID DENTAL | OTHER | 020561 | 05 | AZ | MEDICAID |