Provider Demographics
NPI:1457363418
Name:LITTLE COLORADO EMERGENCY PHYSICIANS LLC
Entity Type:Organization
Organization Name:LITTLE COLORADO EMERGENCY PHYSICIANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:RONAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-401-2386
Mailing Address - Street 1:13737 NOEL RD
Mailing Address - Street 2:STE 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75240-1331
Mailing Address - Country:US
Mailing Address - Phone:469-401-2386
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:1501 N WILLIAMSON AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2735
Practice Address - Country:US
Practice Address - Phone:928-289-4691
Practice Address - Fax:928-289-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0912160OtherBLUE SHIELD
AZ832768Medicaid
AZAZ0866770OtherBLUE SHIELD
AZ832768Medicaid