=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790956415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERMATOLOGY NORTHWEST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 04/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 W ORANGE GROVE RD SUITE 101
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-544-2211
-----------------------------------------------------
Fax | 520-544-2277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1845 W ORANGE GROVE RD SUITE 101
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85704-1134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-544-2211
-----------------------------------------------------
Fax | 520-544-2277
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JAMES E BENNETT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 520-544-2211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 17914
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------