Provider Demographics
NPI:1558563114
Name:FAMILY HEALTH CENTER OF SIERRA VISTA, PC
Entity Type:Organization
Organization Name:FAMILY HEALTH CENTER OF SIERRA VISTA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-459-3116
Mailing Address - Street 1:1800 E WILCOX DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2756
Mailing Address - Country:US
Mailing Address - Phone:520-459-3116
Mailing Address - Fax:520-459-7397
Practice Address - Street 1:1800 E WILCOX DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2756
Practice Address - Country:US
Practice Address - Phone:520-459-3116
Practice Address - Fax:520-459-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16890207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZA002OtherTRICARE WPS
AZHEALTHNETOther1Z4100
AZCH7902OtherRAILROAD MEDICARE
AZWDBTXMedicare ID - Type Unspecified