Provider Demographics
NPI:1205164688
Name:COMMUNITY HEALTH CARE OF DOUGLAS
Entity type:Organization
Organization Name:COMMUNITY HEALTH CARE OF DOUGLAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-805-5940
Mailing Address - Street 1:2174 W OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-6003
Mailing Address - Country:US
Mailing Address - Phone:520-805-5813
Mailing Address - Fax:
Practice Address - Street 1:2174 W OAK AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:AZ
Practice Address - Zip Code:85607
Practice Address - Country:US
Practice Address - Phone:520-805-5813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ55843901Medicaid
AZZ64950Medicare PIN