Provider Demographics
NPI:1043449887
Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Entity Type:Organization
Organization Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Other - Org Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-771-5691
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:7700 E FLORENTINE RD BLDG B
Practice Address - Street 2:SUITE A101
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2245
Practice Address - Country:US
Practice Address - Phone:928-442-8710
Practice Address - Fax:928-442-8742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ126775OtherMEDICARE PTAN
AZ459138Medicaid