Basic Information
| Provider Information | |||||||||
| NPI: | 1841964624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BISBEE HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COPPER QUEEN COMMUNITY HOSPITAL TOMBSTONE RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | COPPER QUEEN COMMUNITY HOSPITAL | ||||||||
| Address2: | 101 COLE AVE | ||||||||
| City: | BISBEE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204322042 | ||||||||
| FaxNumber: | 5204571485 | ||||||||
| Practice Location | |||||||||
| Address1: | BISBEE HOSPITAL ASSOCIATION | ||||||||
| Address2: | 7 NORTH SAN DIEGO ST. | ||||||||
| City: | TOMBSTONE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204322042 | ||||||||
| FaxNumber: | 5204571485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SEAMON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5204326400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | N | Managed Care Organizations | Point of Service | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.