Provider Demographics
NPI:1164776845
Name:CAMELBACK MOUNTAIN MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:CAMELBACK MOUNTAIN MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:GRIFFIN
Authorized Official - Last Name:CIPOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-266-4383
Mailing Address - Street 1:120 E MONTEREY WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2618
Mailing Address - Country:US
Mailing Address - Phone:602-266-4383
Mailing Address - Fax:602-266-4384
Practice Address - Street 1:120 E MONTEREY WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2618
Practice Address - Country:US
Practice Address - Phone:602-266-4383
Practice Address - Fax:602-266-4384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ341769Medicaid
AZG19491Medicare UPIN
AZZ61746Medicare PIN