Provider Demographics
NPI:1881680122
Name:ARIZONA INSTITUTE OF MEDICINE AND SURGERY
Entity Type:Organization
Organization Name:ARIZONA INSTITUTE OF MEDICINE AND SURGERY
Other - Org Name:OUTPATIENT TREATMENT CTR
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AZAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-757-3636
Mailing Address - Street 1:3636 STOCKTON HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409
Mailing Address - Country:US
Mailing Address - Phone:928-757-3680
Mailing Address - Fax:928-757-3614
Practice Address - Street 1:3636 STOCKTON HILL ROAD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409
Practice Address - Country:US
Practice Address - Phone:928-757-3680
Practice Address - Fax:928-757-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6602085B0100X, 2085R0202X
261QU0200X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167933Medicaid
61909Medicare PIN
AZ167933Medicaid
62458Medicare PIN