Provider Demographics
NPI:1992901672
Name:OB-GYN WOMEN'S CENTER, PC
Entity type:Organization
Organization Name:OB-GYN WOMEN'S CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:PITUCH
Authorized Official - Last Name:IMMESBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-514-8602
Mailing Address - Street 1:3003 HIGHWAY 95
Mailing Address - Street 2:SUITE 39
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86429
Mailing Address - Country:US
Mailing Address - Phone:928-758-1010
Mailing Address - Fax:928-758-1428
Practice Address - Street 1:3003 HIGHWAY 95
Practice Address - Street 2:SUITE 39
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86429
Practice Address - Country:US
Practice Address - Phone:928-758-1010
Practice Address - Fax:928-758-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ145525Medicaid
AZZWMBTRMedicare PIN