Provider Demographics
NPI:1760623870
Name:VILLAGE OF OAK CREEK MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:VILLAGE OF OAK CREEK MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ZARETZKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-284-3236
Mailing Address - Street 1:PO BOX 1936
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-1936
Mailing Address - Country:US
Mailing Address - Phone:928-634-0665
Mailing Address - Fax:928-634-0337
Practice Address - Street 1:6486 HWY 179
Practice Address - Street 2:STE 107
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-7993
Practice Address - Country:US
Practice Address - Phone:928-284-3236
Practice Address - Fax:928-284-2531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23452207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ357287Medicaid
AZZMD23452Medicare PIN