Provider Demographics
NPI:1942271788
Name:WHITE MOUNTAIN INTERNAL MEDICINE, PC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-774-3135
Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1479
Mailing Address - Country:US
Mailing Address - Phone:928-774-3135
Mailing Address - Fax:928-774-3134
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-774-3135
Practice Address - Fax:928-774-3134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty