Healthcare Provider Details

I. General information

NPI: 1659614113
Provider Name (Legal Business Name): AZ NORTH PAIN & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 N STEVES BLVD
FLAGSTAFF AZ
86004-3938
US

IV. Provider business mailing address

PO BOX 2520
FLAGSTAFF AZ
86003-2520
US

V. Phone/Fax

Practice location:
  • Phone: 928-226-7191
  • Fax:
Mailing address:
  • Phone: 928-226-7191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT MICHAEL DAHL
Title or Position: PRESIDENT
Credential:
Phone: 928-226-7191