Provider Demographics
NPI:1134673254
Name:INDEPENDENT MEDICAL AND SURGICAL
Entity Type:Organization
Organization Name:INDEPENDENT MEDICAL AND SURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-649-2600
Mailing Address - Street 1:401 S CALVARY WAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4165
Mailing Address - Country:US
Mailing Address - Phone:928-649-2600
Mailing Address - Fax:928-634-7847
Practice Address - Street 1:401 S CALVARY WAY
Practice Address - Street 2:SUITE D
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4165
Practice Address - Country:US
Practice Address - Phone:928-649-2600
Practice Address - Fax:928-634-7847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty