Provider Demographics
NPI:1578028684
Name:CAVE CREEK CLINIC, LLC
Entity Type:Organization
Organization Name:CAVE CREEK CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-401-1555
Mailing Address - Street 1:15029 N THOMPSON PEAK PKWY # B111-438
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2217
Mailing Address - Country:US
Mailing Address - Phone:480-401-1555
Mailing Address - Fax:800-930-4408
Practice Address - Street 1:2920 E MOHAWK LN STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4773
Practice Address - Country:US
Practice Address - Phone:480-401-1555
Practice Address - Fax:800-930-4408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ388615Medicaid
AZ600874Medicaid