=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780984765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOTHILLS GASTROENTEROLOGY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2010
-----------------------------------------------------
Last Update Date | 10/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1521 E TANGERINE RD SUITE 361
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-6225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-818-3680
-----------------------------------------------------
Fax | 520-818-3690
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 E TANGERINE RD SUITE 361
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-6225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-818-3680
-----------------------------------------------------
Fax | 520-818-3690
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MS. ALISON R LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-818-3680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 30996
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------