Provider Demographics
NPI:1508072844
Name:MOUNT GRAHAM FAMILY MEDICINE PRACTICE,P.C.
Entity Type:Organization
Organization Name:MOUNT GRAHAM FAMILY MEDICINE PRACTICE,P.C.
Other - Org Name:DBA MOUNT GRAHAM FAMILY PRACTICE, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KARTCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-428-3122
Mailing Address - Street 1:1300 S. 20TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546
Mailing Address - Country:US
Mailing Address - Phone:928-428-3122
Mailing Address - Fax:928-428-7917
Practice Address - Street 1:1300 S. 20TH AVENUE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-428-3122
Practice Address - Fax:928-428-7917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ26661Medicare PIN