Provider Demographics
NPI:1528394830
Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Entity Type:Organization
Organization Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE LLC
Other - Org Name:YAVAPAI REGIONAL MEDICAL CENTER PHYSICIAN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-771-5691
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:802 AINSWORTH DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1623
Practice Address - Country:US
Practice Address - Phone:928-445-6025
Practice Address - Fax:928-778-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ475065OtherAHCCCS
AZZ126775Medicare PIN