Provider Demographics
NPI:1639313240
Name:FLAIZ, RAYMOND J (IDMT)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:FLAIZ
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:J
Other - Last Name:FLAIZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IDMT
Mailing Address - Street 1:375 MDG/SGOPG
Mailing Address - Street 2:
Mailing Address - City:SCOTT AFB
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:618-256-7230
Mailing Address - Fax:
Practice Address - Street 1:312 W. LOSEY STR
Practice Address - Street 2:375 MDG/SGOPG
Practice Address - City:SCOTT AFB
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-7230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians