Provider Demographics
NPI:1659445062
Name:NORTHERN ARIZONA EYE ASSOCIATES
Entity Type:Organization
Organization Name:NORTHERN ARIZONA EYE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-779-7000
Mailing Address - Street 1:900 N SAN FRANCISCO ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3236
Mailing Address - Country:US
Mailing Address - Phone:928-779-7000
Mailing Address - Fax:
Practice Address - Street 1:900 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3236
Practice Address - Country:US
Practice Address - Phone:928-779-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ290066Medicaid
DG6643OtherMEDICARE RAILROAD GROUP ID
180022943OtherMEDICARE RR GROUP ID
AZZ103291Medicare PIN