MEDICARE: HAVASU REGIONAL MEDICAL 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	207R00000X	Internal Medicine Physician	APPLIED FOR	AZ
2	2085R0202X	Diagnostic Radiology Physician	APPLIED FOR	AZ
3	208D00000X	General Practice Physician	APPLIED FOR	AZ
4	207P00000X	Emergency Medicine Physician	APPLIED FOR	AZ

General Provider Information

NPI Number	:	1972825644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU REGIONAL MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	330 SEVEN SPRINGS WAY
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-4536
Country	:	US
Telephone Number	:	615-920-7000
Fax Number	:	615-920-8913

Provider Business Practice Location Address
First Line	:	1799 KIOWA AVE
Second Line	:	# 104
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-2881
Country	:	US
Telephone Number	:	928-505-1030
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	TERRANCE DILLON
Credential	:
Telephone Number	:	502-596-7220

Provider Enumeration Date	:	02/23/2010
Last Update Date	:	04/25/2022

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