Basic Information
| Provider Information | |||||||||
| NPI: | 1316152333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AZ CORRIDOR EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3916 STATE ST | ||||||||
| Address2: | #300 | ||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931055602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055633011 | ||||||||
| FaxNumber: | 8055633011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E FLORENCE BLVD | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852225303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203816300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2007 | ||||||||
| LastUpdateDate: | 01/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | GODBOLD | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8055633011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DG3676 | 01 | AZ | RAILROAD MEDICARE | OTHER | 224499 | 05 | AZ | MEDICAID |