Provider Demographics
NPI:1841527645
Name:HAVASU LUNG AND SLEEP DISORDERS CENTER LLC
Entity type:Organization
Organization Name:HAVASU LUNG AND SLEEP DISORDERS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERDIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-855-6966
Mailing Address - Street 1:PO BOX 4559
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-4559
Mailing Address - Country:US
Mailing Address - Phone:928-855-6966
Mailing Address - Fax:928-855-6974
Practice Address - Street 1:1830 MESQUITE AVE
Practice Address - Street 2:STE C
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5885
Practice Address - Country:US
Practice Address - Phone:928-855-6966
Practice Address - Fax:928-855-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-16
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42565207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL-1566579-8OtherCORPORATION NUMBER
AZ480404Medicaid
AZ480404Medicaid