Provider Demographics
NPI:1003996224
Name:WEST FAMILY PRACTICE AND OBSTETRICS
Entity Type:Organization
Organization Name:WEST FAMILY PRACTICE AND OBSTETRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-788-9378
Mailing Address - Street 1:PO BOX 8400
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-8400
Mailing Address - Country:US
Mailing Address - Phone:928-788-9378
Mailing Address - Fax:928-788-9381
Practice Address - Street 1:1510 E WAGON WHEEL LN
Practice Address - Street 2:SUITE 106
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6697
Practice Address - Country:US
Practice Address - Phone:928-788-9378
Practice Address - Fax:928-788-9381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27671261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109137OtherMEDICARE ID-PIN
AZZ109137OtherMEDICARE ID-PIN
AZG91143Medicare UPIN