Provider Demographics
NPI:1851544456
Name:EXTREMITY MEDICAL
Entity Type:Organization
Organization Name:EXTREMITY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-405-5105
Mailing Address - Street 1:1601 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-1707
Mailing Address - Country:US
Mailing Address - Phone:602-405-5105
Mailing Address - Fax:602-391-2110
Practice Address - Street 1:1601 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-1707
Practice Address - Country:US
Practice Address - Phone:602-405-5105
Practice Address - Fax:602-391-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies