Provider Demographics
NPI:1346800646
Name:MOUNTAINSIDE MEDICAL CLINIC
Entity Type:Organization
Organization Name:MOUNTAINSIDE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LIBAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:480-687-7190
Mailing Address - Street 1:PO BOX 9365
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-0139
Mailing Address - Country:US
Mailing Address - Phone:480-687-7190
Mailing Address - Fax:480-687-7292
Practice Address - Street 1:4139 W BELL RD STE 8&9
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2753
Practice Address - Country:US
Practice Address - Phone:507-319-7780
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty