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General NPI Number Information
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NPI Number | 1336104462
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Entity Type | Organization
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Legal Business Name | SMITH TRYON FAMILY HEALTH INC D.B.A. BLUE WATER MEDICAL
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Dates
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Enumeration Date | 04/20/2006
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Last Update Date | 09/27/2010
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Provider Practice Location Address
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Address Line | 1801 MESQUITE AVE
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5664
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Country | US
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Telephone | 928-453-6963
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Fax | 928-453-7015
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Provider Business Mailing Address
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Address Line | 1990 MCCULLOCH BLVD N SUITE D, BOX 379D
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5749
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Country | US
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Telephone | 928-453-6963
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Fax | 928-453-7015
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ELIZABETH ANNE SMITH TRYON
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Credential | MD
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Telephone | 928-453-6963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 35026
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 2768
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35026
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License Number State | AZ
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