Basic Information
| Provider Information | |||||||||
| NPI: | 1497958904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOTHILLS SURGERY P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53587 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850723587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727634 | ||||||||
| FaxNumber: | 5208727969 | ||||||||
| Practice Location | |||||||||
| Address1: | 4530 E. CAMP LOWELL ROAD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203201200 | ||||||||
| FaxNumber: | 5203201222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | BCAUVAIS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5203201200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 33951 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 951899 | 05 | AZ | MEDICAID |