Provider Demographics
NPI:1568512580
Name:KINGMAN GENERAL SURGERY PC
Entity Type:Organization
Organization Name:KINGMAN GENERAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:C
Authorized Official - Last Name:TANDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-681-4440
Mailing Address - Street 1:1739 E BEVERLY AVE
Mailing Address - Street 2:SUITE 218
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:928-681-4440
Mailing Address - Fax:928-681-4443
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-4440
Practice Address - Fax:928-681-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35696208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0686409Medicaid
NJ057206Medicare ID - Type Unspecified
NJ0686409Medicaid