Provider Demographics
NPI:1114239019
Name:OASIS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:OASIS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-453-1101
Mailing Address - Street 1:P.O. BOX 1185
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-1185
Mailing Address - Country:US
Mailing Address - Phone:928-453-1101
Mailing Address - Fax:928-453-1171
Practice Address - Street 1:2035 MESQUITE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5894
Practice Address - Country:US
Practice Address - Phone:928-453-1101
Practice Address - Fax:928-453-1171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZL-1602910-3OtherAZ LLC REGISTRATION
AZ535744Medicaid
AZ535744Medicaid