Provider Demographics
NPI:1164487922
Name:WHITE MOUNTAIN SURGICAL SPECIALISTS PC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN SURGICAL SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-537-4240
Mailing Address - Street 1:2650 E SHOW LOW LAKE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7955
Mailing Address - Country:US
Mailing Address - Phone:928-537-4240
Mailing Address - Fax:928-537-4541
Practice Address - Street 1:2650 E SHOW LOW LAKE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7955
Practice Address - Country:US
Practice Address - Phone:928-537-4240
Practice Address - Fax:928-537-4541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC0061261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ3C0001079Medicare PIN