Provider Demographics
NPI:1962657783
Name:ARIZONA INSTITURE OF MEDICINE & SURGERY
Entity Type:Organization
Organization Name:ARIZONA INSTITURE OF MEDICINE & SURGERY
Other - Org Name:OUTPATIEN TREATMENT CTR
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
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 RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0514
Mailing Address - Country:US
Mailing Address - Phone:928-757-3680
Mailing Address - Fax:928-757-3614
Practice Address - Street 1:3636 STOCKTON HILL RD
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:2008-11-20
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-0660261QU0200X, 335V00000X
AZ03D0534286291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ167933Medicaid
AZOTC-0660OtherMEDICAL FACILITY LICENSING