Provider Demographics
NPI:1720218860
Name:SIERRA VISTA OBSTETRICS & GYNECOLOGY INC
Entity type:Organization
Organization Name:SIERRA VISTA OBSTETRICS & GYNECOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNCKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-705-7300
Mailing Address - Street 1:75 COLONIA DE SALUD
Mailing Address - Street 2:STE 100B
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2487
Mailing Address - Country:US
Mailing Address - Phone:480-705-7300
Mailing Address - Fax:480-705-7301
Practice Address - Street 1:75 COLONIA DE SALUD
Practice Address - Street 2:STE 100B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2487
Practice Address - Country:US
Practice Address - Phone:480-705-7300
Practice Address - Fax:480-705-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25845207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZA92250Medicare UPIN