Provider Demographics
NPI:1770762841
Name:CARDIAC & PERIPHERAL VASCULAR SPECIALS OF NORTHERN ARIZONA
Entity type:Organization
Organization Name:CARDIAC & PERIPHERAL VASCULAR SPECIALS OF NORTHERN ARIZONA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-213-1051
Mailing Address - Street 1:2532 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-3712
Mailing Address - Country:US
Mailing Address - Phone:928-213-1051
Mailing Address - Fax:928-213-1053
Practice Address - Street 1:1515 E CEDAR AVE STE D-2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1638
Practice Address - Country:US
Practice Address - Phone:928-213-1051
Practice Address - Fax:928-213-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ983206Medicaid