Provider Demographics
NPI:1619057932
Name:ARIZONA MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:ARIZONA MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MANJUNATH
Authorized Official - Middle Name:
Authorized Official - Last Name:NATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-328-8393
Mailing Address - Street 1:2095 W 24TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6243
Mailing Address - Country:US
Mailing Address - Phone:928-328-8393
Mailing Address - Fax:
Practice Address - Street 1:2095 W 24TH ST STE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6243
Practice Address - Country:US
Practice Address - Phone:928-328-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ153563Medicaid
AZ153563Medicaid