1770549974 NPI number — MT GRAHAM REGIONAL MEDICAL CENTER INC

Table of content: (NPI 1770549974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770549974 NPI number — MT GRAHAM REGIONAL MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT GRAHAM REGIONAL MEDICAL CENTER INC
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:
Provider Other Organization Name Type Code:
6
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:
1770549974
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 S. 20TH AVE
Provider Second Line Business Mailing Address:
BLDG. E
Provider Business Mailing Address City Name:
SAFFORD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-348-4063
Provider Business Mailing Address Fax Number:
928-348-3868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S. 20TH AVE
Provider Second Line Business Practice Location Address:
BLDG. E
Provider Business Practice Location Address City Name:
SAFFORD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-348-4063
Provider Business Practice Location Address Fax Number:
928-348-3868
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRYCE
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
928-348-4099

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  HSPC-43 , 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: 317786 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03D0886073 . This is a "CLIA NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: HSPC-43 . This is a "ADHS NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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