Provider Demographics
NPI:1942326020
Name:AVALON BIOTECHNICAL CORPORATION
Entity Type:Organization
Organization Name:AVALON BIOTECHNICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:BAUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-368-8200
Mailing Address - Street 1:PO BOX 1912
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85902-1912
Mailing Address - Country:US
Mailing Address - Phone:928-368-8200
Mailing Address - Fax:928-368-8208
Practice Address - Street 1:3364 KAY RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5405
Practice Address - Country:US
Practice Address - Phone:928-368-8200
Practice Address - Fax:928-368-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15235207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ103100Medicare PIN