1992929004 NPI number — GILA VALLEY MEDICAL GROUP LLC

Table of content: (NPI 1992929004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992929004 NPI number — GILA VALLEY MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GILA VALLEY MEDICAL GROUP 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:
Provider Other Organization Name Type Code:
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:
1992929004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1951 WEST 25TH STREET
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
YUMA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-344-6263
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1951 WEST 25TH STREET
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
YUMA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-344-6263
Provider Business Practice Location Address Fax Number:
928-785-9572
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKSHER
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-344-6263

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  20396 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 2125 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 076275001 . This is a "AACCS" identifier . This identifiers is of the category "OTHER".




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