Basic Information
| Provider Information | |||||||||
| NPI: | 1801069158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK HILLS UROLOGY GROUP, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 294 W STATE ROUTE 89A | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863263754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286497970 | ||||||||
| FaxNumber: | 9286497971 | ||||||||
| Practice Location | |||||||||
| Address1: | 294 W STATE ROUTE 89A | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863263754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286497970 | ||||||||
| FaxNumber: | 9286497971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAMPENNI | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CO.OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9286497970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 36999 | AZ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208800000X | 4639 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 328233 | 05 | AZ | MEDICAID | 4639 | 01 | AZ | FOR DR. MICHAEL CAMPENNI | OTHER | 1801069158 | 01 | AZ | GROUP NPI FOR BLACK HILLS UROLOGY | OTHER | 36999 | 01 | AZ | FOR DR. STEVEN KURZWEIL | OTHER | 324852 | 05 | AZ | MEDICAID |