MEDICARE: HAVASU LUNG AND SLEEP DISORDERS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	42565	AZ
2	207RS0012X	Sleep Medicine (Internal Medicine) Physician	42565	AZ
3	207RP1001X	Pulmonary Disease Physician	42565	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L-1566579-8	OTHER	AZ	CORPORATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841527645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU LUNG AND SLEEP DISORDERS CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 4559
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-4559
Country	:	US
Telephone Number	:	928-855-6966
Fax Number	:	928-855-6974

Provider Business Practice Location Address
First Line	:	1830 MESQUITE AVE
Second Line	:	STE C
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5885
Country	:	US
Telephone Number	:	928-855-6966
Fax Number	:	928-855-6974

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	HEIDI A BERDIN
Credential	:	M.D.
Telephone Number	:	928-855-6966

Provider Enumeration Date	:	11/16/2009
Last Update Date	:	10/25/2010

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