Provider Demographics
NPI:1922105204
Name:MOUNTAIN PARK HEALTH CENTER
Entity Type:Organization
Organization Name:MOUNTAIN PARK HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SWAGERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-323-3344
Mailing Address - Street 1:3003 N CENTRAL AVE STE 1600
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2908
Mailing Address - Country:US
Mailing Address - Phone:602-323-3344
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:140 N LITCHFIELD RD STE 200&106
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1277
Practice Address - Country:US
Practice Address - Phone:623-936-6795
Practice Address - Fax:623-478-8150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN PARK HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 261QF0400X
AZOTC4975261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
031844Medicare PIN
031844Medicare Oscar/Certification
AZ031844Medicare Oscar/Certification