Provider Demographics
NPI:1700940202
Name:AZ ORTHO & JNT REPLACE CNTR
Entity Type:Organization
Organization Name:AZ ORTHO & JNT REPLACE CNTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERGHAUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-881-2600
Mailing Address - Street 1:1951 N WILMOT RD
Mailing Address - Street 2:BLDG 2
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-8000
Mailing Address - Country:US
Mailing Address - Phone:520-881-2600
Mailing Address - Fax:520-881-2844
Practice Address - Street 1:630 N ALVERNON WAY STE 161
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1895
Practice Address - Country:US
Practice Address - Phone:520-881-2600
Practice Address - Fax:520-881-2844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30321174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ694902Medicaid
AZ694902Medicaid