Provider Demographics
NPI:1417222969
Name:PALO VERDE FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:PALO VERDE FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-878-5800
Mailing Address - Street 1:PO BOX 4196
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4100
Mailing Address - Country:US
Mailing Address - Phone:623-878-5800
Mailing Address - Fax:623-878-5807
Practice Address - Street 1:7615 W THUNDERBIRD RD
Practice Address - Street 2:STE 106
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6083
Practice Address - Country:US
Practice Address - Phone:623-878-5800
Practice Address - Fax:623-878-5807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ696933Medicaid
AZZ90022Medicare PIN