Provider Demographics
NPI:1851469720
Name:NORTHERN ARIZONA GENERAL SURGICAL GROUP PC
Entity Type:Organization
Organization Name:NORTHERN ARIZONA GENERAL SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:COURSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-303-9593
Mailing Address - Street 1:3880 STOCKTON HILL RD
Mailing Address - Street 2:#103-128
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0595
Mailing Address - Country:US
Mailing Address - Phone:928-303-9593
Mailing Address - Fax:
Practice Address - Street 1:3880 STOCKTON HILL RD
Practice Address - Street 2:#103-128
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0595
Practice Address - Country:US
Practice Address - Phone:928-303-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30616208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ726044Medicaid
AZZ71275Medicare ID - Type Unspecified
AZ726044Medicaid