Provider Demographics
NPI:1619247939
Name:MKG INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:MKG INTERNAL MEDICINE PLLC
Other - Org Name:DESERT ROSE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:GABBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-291-1784
Mailing Address - Street 1:21001 N TATUM BLVD
Mailing Address - Street 2:STE 1630-156
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4206
Mailing Address - Country:US
Mailing Address - Phone:602-291-1784
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR
Practice Address - Street 2:BLDG 6, STE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:602-291-1784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-03
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ670364Medicaid
AZ670364Medicaid