Provider Demographics
NPI:1558548487
Name:INTERNAL MEDICINE SPECIALISTS OF PRESCOTT VALLEY ARIZONA,PC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE SPECIALISTS OF PRESCOTT VALLEY ARIZONA,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:GALE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-772-1845
Mailing Address - Street 1:3223 N WINDSONG DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1222
Mailing Address - Country:US
Mailing Address - Phone:928-772-1845
Mailing Address - Fax:928-772-1844
Practice Address - Street 1:3223 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1222
Practice Address - Country:US
Practice Address - Phone:928-772-1845
Practice Address - Fax:928-772-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2772261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105775Medicare PIN