Provider Demographics
NPI:1366626400
Name:HIGLEY FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:HIGLEY FAMILY MEDICINE, LLC
Other - Org Name:OLIVEVIEW HOMEFRONT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHITMORE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:480-988-6878
Mailing Address - Street 1:1425 S HIGLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4798
Mailing Address - Country:US
Mailing Address - Phone:480-988-6878
Mailing Address - Fax:480-988-6879
Practice Address - Street 1:1425 S HIGLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4798
Practice Address - Country:US
Practice Address - Phone:480-988-6878
Practice Address - Fax:480-988-6879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2399207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ560674Medicaid
AZ228810Medicaid
AZ286791Medicaid
AZE00288Medicare UPIN
AZI19062Medicare UPIN
AZP33277Medicare UPIN