Provider Demographics
NPI:1568470276
Name:BATES, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:BATES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1479
Mailing Address - Country:US
Mailing Address - Phone:928-773-2505
Mailing Address - Fax:928-773-2504
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-773-2505
Practice Address - Fax:928-773-2504
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29995207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ765109Medicaid
AZ050089746Medicare PIN
AZZ71609Medicare PIN
AZ765109Medicaid
AZH71883Medicare UPIN