1205962792 NPI number — MEDCOM MEDICAL, LLC

Table of content: (NPI 1205962792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205962792 NPI number — MEDCOM MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDCOM MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PALO VERDE FAMILY CARE, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205962792
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1508
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAYPOOL
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-402-0952
Provider Business Mailing Address Fax Number:
928-402-4774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 SOUTH BROAD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLOBE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-425-6592
Provider Business Practice Location Address Fax Number:
928-425-7566
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDRADE
Authorized Official First Name:
OSCAR
Authorized Official Middle Name:
ERNESTO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-402-0952

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  27758 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1225107667 . This is a "SHERIDA CARLSON PA NPI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 475592 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1871545905 . This is a "JEAN TURNEY-SHAW FPN NPI" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1275685521 . This is a "AZ NPI OSCAR ERNEST ANDRA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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