=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962212340
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSS RAZINN MANAGER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 05/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13827 N 41ST PL
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85032-5815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-449-8494
-----------------------------------------------------
Fax | 855-288-9241
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 W PASADENA AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85013-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-803-9575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 145292
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 166955
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------