Basic Information
| Provider Information | |||||||||
| NPI: | 1376698365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWESTERN NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1951 N WILMOT RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857128000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207223777 | ||||||||
| FaxNumber: | 5202966224 | ||||||||
| Practice Location | |||||||||
| Address1: | 13101 N ORACLE RD | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857399554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208254711 | ||||||||
| FaxNumber: | 5208254712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | PIERPONT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5208254711 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261Q00000X | 24067 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | Z67518 | 01 | AZ | MEDICARE PTAN | OTHER |