Provider Demographics
NPI:1669455515
Name:THOMAS G DALLMAN MD PC
Entity Type:Organization
Organization Name:THOMAS G DALLMAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:DALLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-763-9505
Mailing Address - Street 1:1355 RAMAR RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7100
Mailing Address - Country:US
Mailing Address - Phone:928-763-9505
Mailing Address - Fax:928-763-7370
Practice Address - Street 1:1355 RAMAR RD
Practice Address - Street 2:SUITE 12
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7100
Practice Address - Country:US
Practice Address - Phone:928-763-9505
Practice Address - Fax:928-763-7370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16390207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0189940OtherBLUE CROSS BLUE SHIELD
C99332Medicare UPIN
AZ=========Medicare ID - Type Unspecified