=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467775957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUIS J PROCHNICKI, M.D. , P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2010
-----------------------------------------------------
Last Update Date | 03/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 S GILBERT RD 102
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-632-7707
-----------------------------------------------------
Fax | 480-926-1600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1121 S GILBERT RD 102
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85204-5235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-632-7707
-----------------------------------------------------
Fax | 480-926-1600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. LOUIS J PROCHNICKI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 480-632-7707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 13402
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------