=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013185669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST INTERVENTIONAL ANESTHESIOLOGY PAIN MANAGEMENTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2008
-----------------------------------------------------
Last Update Date | 02/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10640 N 28TH DR SUITE C-106
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85029-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-863-3924
-----------------------------------------------------
Fax | 602-863-3926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 94568
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85070-4568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-361-7680
-----------------------------------------------------
Fax | 480-361-7683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JAMES H DIEDE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 480-361-7680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 48915
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------