Basic Information
| Provider Information | |||||||||
| NPI: | 1588854145 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARFIGHTER, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1070 | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853661070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287264234 | ||||||||
| FaxNumber: | 9287264241 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283442000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | RUNYAN | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9287264234 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | 3599 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | XPY195112 | 05 | AZ | MEDICAID |