Provider Demographics
NPI:1548426489
Name:ARIZONA FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:ARIZONA FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-680-4233
Mailing Address - Street 1:PO BOX 3510
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-3510
Mailing Address - Country:US
Mailing Address - Phone:928-680-4233
Mailing Address - Fax:928-680-6522
Practice Address - Street 1:2082 MESQUITE AVE
Practice Address - Street 2:SUITE A106
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6710
Practice Address - Country:US
Practice Address - Phone:928-680-4233
Practice Address - Fax:928-680-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080153530OtherRAILROAD MEDICARE
AZAZ0327480OtherBLUE CROSS BLUE SHIELD
AZZ24643OtherMEDICARE GROUP #
AZ1Z9241OtherHEALTH NET
AZ016122Medicaid
AZAZ0327480OtherBLUE CROSS BLUE SHIELD