Provider Demographics
NPI:1982090338
Name:ARIZONA BLEEDING DISORDERS HEALTH AND WELLNESS CENTER
Entity type:Organization
Organization Name:ARIZONA BLEEDING DISORDERS HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRBY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-857-3900
Mailing Address - Street 1:821 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1315
Mailing Address - Country:US
Mailing Address - Phone:602-680-7722
Mailing Address - Fax:602-682-5135
Practice Address - Street 1:821 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-1315
Practice Address - Country:US
Practice Address - Phone:602-680-7722
Practice Address - Fax:602-682-5135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-13
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6802208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC6802OtherOUTPATIENT TREATMENT CENTER LICENCE