Provider Demographics
NPI:1306009519
Name:MOUNTAIN HEART MEDICAL PRACTICE PLLC
Entity Type:Organization
Organization Name:MOUNTAIN HEART MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:9028-226-6400
Mailing Address - Street 1:2000 S THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8759
Mailing Address - Country:US
Mailing Address - Phone:928-226-6400
Mailing Address - Fax:928-226-6411
Practice Address - Street 1:2000 S THOMPSON ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8759
Practice Address - Country:US
Practice Address - Phone:928-226-6400
Practice Address - Fax:928-226-6411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30420207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty