Healthcare Provider Details

I. General information

NPI: 1639313240
Provider Name (Legal Business Name): RAYMOND J FLAIZ IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RAYMOND J FLAIZ IDMT

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W. LOSEY STR 375 MDG/SGOPG
SCOTT AFB IL
62225
US

IV. Provider business mailing address

375 MDG/SGOPG
SCOTT AFB IL
62225
US

V. Phone/Fax

Practice location:
  • Phone: 618-256-7230
  • Fax:
Mailing address:
  • Phone: 618-256-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: