Provider Demographics
NPI:1790844595
Name:SOUTHWEST HEART AND LUNG FLAGSTAFF
Entity Type:Organization
Organization Name:SOUTHWEST HEART AND LUNG FLAGSTAFF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CASKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-263-7600
Mailing Address - Street 1:10930 N TATUM BLVD
Mailing Address - Street 2:103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6069
Mailing Address - Country:US
Mailing Address - Phone:602-263-7600
Mailing Address - Fax:602-212-0365
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2200
Practice Address - Fax:602-212-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35512174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ76454Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER