Provider Demographics
NPI:1962621375
Name:EASTERN ARIZONA ORTHOPEDIC CLINIC PC
Entity type:Organization
Organization Name:EASTERN ARIZONA ORTHOPEDIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-425-3193
Mailing Address - Street 1:5860 S HOSPITAL DR
Mailing Address - Street 2:STE 103
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-9449
Mailing Address - Country:US
Mailing Address - Phone:928-425-3193
Mailing Address - Fax:928-425-4771
Practice Address - Street 1:5860 S HOSPITAL DR
Practice Address - Street 2:STE103
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9449
Practice Address - Country:US
Practice Address - Phone:928-425-3193
Practice Address - Fax:928-425-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11804174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ235102Medicaid
AZ20WCGDT01Medicare ID - Type Unspecified
AZ235102Medicaid
AZE44419Medicare UPIN