Provider Demographics
NPI:1346528759
Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Other - Org Name:COPPER MOUNTAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OUTPATIENT CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-348-4037
Mailing Address - Street 1:2250 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4081
Mailing Address - Country:US
Mailing Address - Phone:928-348-4037
Mailing Address - Fax:844-271-2379
Practice Address - Street 1:2250 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4081
Practice Address - Country:US
Practice Address - Phone:928-348-4037
Practice Address - Fax:844-271-2379
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT GRAHAM REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-02
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ920739Medicaid
AZ964830Medicaid
AZ964830Medicaid