Healthcare Provider Details

I. General information

NPI: 1790977825
Provider Name (Legal Business Name): MARC ANDREW ZUCH LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 NORTH BEAVER STREET
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

1200 N BEAVER ST FLAGSTAFF MEDICAL CENTER BHS
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-213-6400
  • Fax:
Mailing address:
  • Phone: 928-231-6400
  • Fax: 928-213-6409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10533
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: