Provider Demographics
NPI:1407837149
Name:THUNDERBIRD INTERNAL MEDICINE, LTD.
Entity Type:Organization
Organization Name:THUNDERBIRD INTERNAL MEDICINE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-938-6960
Mailing Address - Street 1:5620 W. THUNDERBIRD RD.
Mailing Address - Street 2:SUITE F-1
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4652
Mailing Address - Country:US
Mailing Address - Phone:602-938-6960
Mailing Address - Fax:602-938-6069
Practice Address - Street 1:5620 W. THUNDERBIRD RD.
Practice Address - Street 2:SUITE F-1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4652
Practice Address - Country:US
Practice Address - Phone:602-938-6960
Practice Address - Fax:602-938-6069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6365970001Medicare NSC
AZZWCGBRMedicare PIN