Provider Demographics
NPI:1548389265
Name:PIERPONT MEDICAL GROUP, LTD
Entity Type:Organization
Organization Name:PIERPONT MEDICAL GROUP, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-830-1040
Mailing Address - Street 1:9221 E BASELINE RD
Mailing Address - Street 2:SUITE A109, #289
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-8310
Mailing Address - Country:US
Mailing Address - Phone:480-830-1040
Mailing Address - Fax:480-981-3130
Practice Address - Street 1:4852 E BASELINE RD
Practice Address - Street 2:SUITE #103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4627
Practice Address - Country:US
Practice Address - Phone:480-830-1040
Practice Address - Fax:480-981-3130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ108917Medicare PIN