Provider Demographics
NPI:1275074015
Name:NICHOLAS A. RANSOM PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NICHOLAS A. RANSOM PROFESSIONAL CORPORATION
Other - Org Name:NICHOLAS A RANSOM PROFESSIONAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-396-4798
Mailing Address - Street 1:1701 WEST ST.MARYS ROAD
Mailing Address - Street 2:STE 114
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2621
Mailing Address - Country:US
Mailing Address - Phone:520-360-1668
Mailing Address - Fax:
Practice Address - Street 1:1701 W SAINT MARYS RD
Practice Address - Street 2:STE 114
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2621
Practice Address - Country:US
Practice Address - Phone:520-396-4798
Practice Address - Fax:520-495-5287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18436174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ286668Medicaid
AZZMD18436Medicare UPIN
AZ1356316111Medicare Oscar/Certification