Provider Demographics
NPI:1336199199
Name:DHHS-PHS, IHS TUCSON AREA, IHS TUCSON
Entity Type:Organization
Organization Name:DHHS-PHS, IHS TUCSON AREA, IHS TUCSON
Other - Org Name:WESTSIDE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:ACCOUNTING AND BUDGET OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIESSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CPM
Authorized Official - Phone:520-295-2427
Mailing Address - Street 1:7900 S J STOCK RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-7012
Mailing Address - Country:US
Mailing Address - Phone:520-295-2427
Mailing Address - Fax:520-295-2611
Practice Address - Street 1:FEDERAL ROUTE 21
Practice Address - Street 2:
Practice Address - City:PISINEMO VILLAGE
Practice Address - State:AZ
Practice Address - Zip Code:89563
Practice Address - Country:US
Practice Address - Phone:520-362-3130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03D09569818OtherCLIA #
AZ03D09569818OtherCLIA #
AZHSZ173Medicare ID - Type UnspecifiedMEDICARE PART B PROV #