Provider Demographics
NPI:1619174604
Name:MIDWEST INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:MIDWEST INTERNAL MEDICINE PLLC
Other - Org Name:MIDWEST MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:LALANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-453-8500
Mailing Address - Street 1:1840 MESQUITE AVE
Mailing Address - Street 2:SUITE F
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:928-453-5556
Practice Address - Street 1:1840 MESQUITE AVE
Practice Address - Street 2:SUITE B
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:928-453-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC02092OtherRAILROAD MEDICARE
AZ=========OtherEIN NUMBER
AZC02092OtherRAILROAD MEDICARE