Provider Demographics
NPI:1841563244
Name:MADERA MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:MADERA MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-889-8879
Mailing Address - Street 1:100 E AJO WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6105
Mailing Address - Country:US
Mailing Address - Phone:520-889-8879
Mailing Address - Fax:520-294-2911
Practice Address - Street 1:100 E AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6105
Practice Address - Country:US
Practice Address - Phone:520-889-8879
Practice Address - Fax:520-294-2911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2224261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47149Medicare UPIN