Provider Demographics
NPI:1922298561
Name:ARIZONA COAGULATION CONSULTANTS INC
Entity Type:Organization
Organization Name:ARIZONA COAGULATION CONSULTANTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC / TREAS
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:602-997-9161
Mailing Address - Street 1:2505 W BERYL AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-1642
Mailing Address - Country:US
Mailing Address - Phone:602-997-9161
Mailing Address - Fax:602-997-1406
Practice Address - Street 1:2505 W BERYL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-1607
Practice Address - Country:US
Practice Address - Phone:602-997-9161
Practice Address - Fax:602-997-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ3L0008134Medicare PIN