Provider Demographics
NPI:1790974830
Name:SCOTT R HAMBLIN MD, PC
Entity Type:Organization
Organization Name:SCOTT R HAMBLIN MD, PC
Other - Org Name:MOUNTAIN AVENUE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LESUEUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-333-5333
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:SPRINGERVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85938-1610
Mailing Address - Country:US
Mailing Address - Phone:928-333-5333
Mailing Address - Fax:928-333-5100
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9813
Practice Address - Country:US
Practice Address - Phone:928-333-5333
Practice Address - Fax:928-333-5100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23187207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ69312Medicare PIN