Provider Demographics
NPI:1821042904
Name:SOUTHERN ARIZONA EAR NOSE & THROAT
Entity Type:Organization
Organization Name:SOUTHERN ARIZONA EAR NOSE & THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-792-2170
Mailing Address - Street 1:1775 W SAINT MARYS RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2696
Mailing Address - Country:US
Mailing Address - Phone:520-792-2170
Mailing Address - Fax:520-792-9702
Practice Address - Street 1:1775 W SAINT MARYS RD
Practice Address - Street 2:SUITE 211
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2696
Practice Address - Country:US
Practice Address - Phone:520-792-2170
Practice Address - Fax:520-792-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-21
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWCHYTMedicare PIN