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General NPI Number Information
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NPI Number | 1720181332
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Entity Type | Organization
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Legal Business Name | BLUE WATER INTERNAL MEDICINE ASSOCIATES PC
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Dates
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Enumeration Date | 09/07/2006
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Last Update Date | 10/10/2007
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Provider Practice Location Address
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Address Line | 1987 MCCULLOCH BLVD N SUITE 101
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5682
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Country | US
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Telephone | 928-453-6963
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Fax | 928-453-7006
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Provider Business Mailing Address
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Address Line | PO BOX 2760
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86405
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Country | US
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Telephone | 928-453-8100
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Fax | 928-453-8158
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. CATHY BLACKWELL
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Credential |
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Telephone | 928-453-8100
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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 |
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License Number State |
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