Provider Demographics
NPI:1619019049
Name:MIDWEST INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:MIDWEST INTERNAL MEDICINE PLLC
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:A
Authorized Official - Last Name:SKILLERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-453-9593
Mailing Address - Street 1:1840 MESQUITE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-453-8500
Mailing Address - Fax:928-453-3660
Practice Address - Street 1:1840 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5771
Practice Address - Country:US
Practice Address - Phone:928-453-8500
Practice Address - Fax:928-453-3660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCD2092OtherRAILROAD MEDICARE
AZ1198420002Medicare NSC
AZZWCJCWMedicare PIN