Provider Demographics
NPI:1487610218
Name:AHWATUKEE SPORTS AND SPINE PLC
Entity type:Organization
Organization Name:AHWATUKEE SPORTS AND SPINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-763-5808
Mailing Address - Street 1:PO BOX 52817
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2817
Mailing Address - Country:US
Mailing Address - Phone:480-763-5808
Mailing Address - Fax:480-759-0647
Practice Address - Street 1:4530 EAST MUIRWOOD DRIVE
Practice Address - Street 2:STE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048
Practice Address - Country:US
Practice Address - Phone:480-763-5808
Practice Address - Fax:480-759-0647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ65689Medicare ID - Type Unspecified
AZ6340840001Medicare NSC