Provider Demographics
NPI:1720181332
Name:BLUE WATER INTERNAL MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:BLUE WATER INTERNAL MEDICINE ASSOCIATES PC
Other - Org Name:ARIZONA OSTEOPOROSIS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-453-8100
Mailing Address - Street 1:PO BOX 2760
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405
Mailing Address - Country:US
Mailing Address - Phone:928-453-8100
Mailing Address - Fax:928-453-8158
Practice Address - Street 1:1987 MCCULLOCH BLVD N
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5682
Practice Address - Country:US
Practice Address - Phone:928-453-6963
Practice Address - Fax:928-453-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ107164Medicare PIN
AZZ69865Medicare PIN
AZZ109221Medicare PIN