=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720536915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BISBEE HOSPITAL ASSOCIATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2016
-----------------------------------------------------
Last Update Date | 09/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E 5TH ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85607-2859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-432-5383
-----------------------------------------------------
Fax | 520-432-8018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 COLE AVE
-----------------------------------------------------
City | BISBEE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85603-1327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-432-5383
-----------------------------------------------------
Fax | 520-432-8018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JAMES EHASZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-432-6450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | RGH0098
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------