Provider Demographics
NPI:1376778050
Name:TRICARE MEDICAL TRANS LLC
Entity Type:Organization
Organization Name:TRICARE MEDICAL TRANS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHMOUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-1707
Mailing Address - Street 1:1825 W OCOTILLO RD
Mailing Address - Street 2:STE #42
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1257
Mailing Address - Country:US
Mailing Address - Phone:602-368-7307
Mailing Address - Fax:602-368-7308
Practice Address - Street 1:1825 W OCOTILLO RD
Practice Address - Street 2:STE #42
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1257
Practice Address - Country:US
Practice Address - Phone:602-368-7307
Practice Address - Fax:602-368-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-24
Last Update Date:2009-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0096611101Medicaid