Provider Demographics
NPI:1831299932
Name:TUCSON LONG TERM CARE MEDICAL GROUP
Entity Type:Organization
Organization Name:TUCSON LONG TERM CARE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOLHACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-615-6200
Mailing Address - Street 1:1775 E SKYLINE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-1162
Mailing Address - Country:US
Mailing Address - Phone:520-615-6200
Mailing Address - Fax:520-615-6255
Practice Address - Street 1:1775 E SKYLINE DR
Practice Address - Street 2:STE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-1162
Practice Address - Country:US
Practice Address - Phone:520-615-6200
Practice Address - Fax:520-615-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNONE261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23472Medicare ID - Type Unspecified