Healthcare Provider Details

I. General information

NPI: 1336104462
Provider Name (Legal Business Name): SMITH TRYON FAMILY HEALTH INC D.B.A. BLUE WATER MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 MESQUITE AVE
LAKE HAVASU CITY AZ
86403-5664
US

IV. Provider business mailing address

1990 MCCULLOCH BLVD N SUITE D, BOX 379D
LAKE HAVASU CITY AZ
86403-5749
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-6963
  • Fax: 928-453-7015
Mailing address:
  • Phone: 928-453-6963
  • Fax: 928-453-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35026
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35026
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2768
License Number StateAZ

VIII. Authorized Official

Name: DR. ELIZABETH ANNE SMITH TRYON
Title or Position: PRESIDENT
Credential: MD
Phone: 928-453-6963