Provider Demographics
NPI:1760454052
Name:PAYSON HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:PAYSON HOSPITAL CORPORATION
Other - Org Name:PAYSON REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP, GROUP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTACCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-373-9600
Mailing Address - Street 1:PO BOX 844825
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:807 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5542
Practice Address - Country:US
Practice Address - Phone:928-474-3222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAYSON HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-02
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH0089275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03U033Medicare Oscar/Certification