Provider Demographics
NPI:1922435320
Name:MARIANAS MEDICAL PROVIDERS, LLC
Entity Type:Organization
Organization Name:MARIANAS MEDICAL PROVIDERS, LLC
Other - Org Name:MMP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:SA
Authorized Official - Last Name:LIZAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-689-2128
Mailing Address - Street 1:P.O. BOX 3431
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932-8901
Mailing Address - Country:US
Mailing Address - Phone:671-689-2128
Mailing Address - Fax:671-633-4452
Practice Address - Street 1:182 CHALAN MACAJNA
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910-6113
Practice Address - Country:US
Practice Address - Phone:671-689-2128
Practice Address - Fax:671-633-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUF1228XMedicare UPIN
GUCS951XMedicare UPIN
GUBY091WMedicare UPIN
GUDE327XMedicare UPIN