Basic Information
Provider Information | |||||||||
NPI: | 1114904703 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AUC BAYWOOD LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 32950 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850642950 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6024331822 | ||||||||
FaxNumber: | 6022467060 | ||||||||
Practice Location | |||||||||
Address1: | 6553 E BAYWOOD AVE | ||||||||
Address2: | #103 | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 85206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4809856200 | ||||||||
FaxNumber: | 4809852951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 03/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BISKUPSKI | ||||||||
AuthorizedOfficialFirstName: | RENEE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF OPERATIONSQ | ||||||||
AuthorizedOfficialTelephone: | 6024331822 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | OTC 3838 | AZ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 958267 | 05 | AZ |   | MEDICAID |