Basic Information
| Provider Information | |||||||||
| NPI: | 1962621375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTERN ARIZONA ORTHOPEDIC CLINIC PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5860 S HOSPITAL DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | GLOBE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855019449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284253193 | ||||||||
| FaxNumber: | 9284254771 | ||||||||
| Practice Location | |||||||||
| Address1: | 5860 S HOSPITAL DR | ||||||||
| Address2: | STE103 | ||||||||
| City: | GLOBE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855019449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284253193 | ||||||||
| FaxNumber: | 9284254771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ACOSTA | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | TERESA | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9284253193 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11804 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 235102 | 05 | AZ | MEDICAID |