Provider Demographics
NPI:1417568775
Name:INTERNAL MEDICINE SPECIALTY SERVICES LLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE SPECIALTY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M CRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-266-0118
Mailing Address - Street 1:1851 N GEMINI DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1607
Mailing Address - Country:US
Mailing Address - Phone:928-266-0118
Mailing Address - Fax:
Practice Address - Street 1:1851 N GEMINI DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1607
Practice Address - Country:US
Practice Address - Phone:928-266-0118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty