Basic Information
Provider Information | |||||||||
NPI: | 1518402650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED MEDICAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 W CEDAR LANE | ||||||||
Address2: |   | ||||||||
City: | PAYSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 85541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284724675 | ||||||||
FaxNumber: | 9284723431 | ||||||||
Practice Location | |||||||||
Address1: | 111 W CEDAR LN | ||||||||
Address2: |   | ||||||||
City: | PAYSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 855415417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284724675 | ||||||||
FaxNumber: | 9284723431 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2016 | ||||||||
LastUpdateDate: | 12/28/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | SITE SUPERVISOR/MA | ||||||||
AuthorizedOfficialTelephone: | 9284724675 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X |   |   | Y |   | Managed Care Organizations | Exclusive Provider Organization |   |
No ID Information.