Provider Demographics
NPI:1144245127
Name:MICHAEL R DURHAM MD
Entity Type:Organization
Organization Name:MICHAEL R DURHAM MD
Other - Org Name:MICHAEL R DURHAM MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-425-4461
Mailing Address - Street 1:703 E ASH ST
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1865
Mailing Address - Country:US
Mailing Address - Phone:928-425-4467
Mailing Address - Fax:928-425-6166
Practice Address - Street 1:703 E ASH ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1865
Practice Address - Country:US
Practice Address - Phone:928-425-4467
Practice Address - Fax:928-425-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14893208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD43871Medicare UPIN
AZZWMBFFMedicare PIN