Basic Information
Provider Information | |||||||||
NPI: | 1548591720 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COBRE VALLEY REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COBRE VALLEY COMMUNITY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5880 S HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | GLOBE | ||||||||
State: | AZ | ||||||||
PostalCode: | 855019447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284253261 | ||||||||
FaxNumber: | 9284257903 | ||||||||
Practice Location | |||||||||
Address1: | 5880 S HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | GLOBE | ||||||||
State: | AZ | ||||||||
PostalCode: | 855019447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9284253261 | ||||||||
FaxNumber: | 9284257903 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2010 | ||||||||
LastUpdateDate: | 04/07/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENSEN | ||||||||
AuthorizedOfficialFirstName: | NEAL | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9284253261 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 34324 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   | 282NC0060X | H0126 | AZ | N |   | Hospitals | General Acute Care Hospital | Critical Access | 208M00000X | 27116 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 020644 | 05 | AZ |   | MEDICAID |