Provider Demographics
NPI:1033454707
Name:NORTH COUNTRY HEALTHCARE, INC.
Entity Type:Organization
Organization Name:NORTH COUNTRY HEALTHCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NEWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-522-9400
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9400
Mailing Address - Fax:
Practice Address - Street 1:2600 E. SHOW LOW LAKE RD.
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901
Practice Address - Country:US
Practice Address - Phone:928-537-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH COUNTRY HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ70394OtherMEDICARE B PTAN
AZZ70394OtherMEDICARE B PTAN
AZZ70394Medicare PIN
AZ031914Medicare Oscar/Certification