Provider Demographics
NPI:1154453728
Name:PINETOP MEDICAL ASSOCIATES LTD
Entity Type:Organization
Organization Name:PINETOP MEDICAL ASSOCIATES LTD
Other - Org Name:BLUE RIDGE REGIONAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-367-6688
Mailing Address - Street 1:PO BOX 2690
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-2690
Mailing Address - Country:US
Mailing Address - Phone:928-367-6688
Mailing Address - Fax:928-367-4916
Practice Address - Street 1:728 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7027
Practice Address - Country:US
Practice Address - Phone:928-367-6688
Practice Address - Fax:938-367-4916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty