Provider Demographics
NPI:1023130259
Name:ASPEN FAMILY MEDICINE PC
Entity type:Organization
Organization Name:ASPEN FAMILY MEDICINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-774-3627
Mailing Address - Street 1:2912 N WEST ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1974
Mailing Address - Country:US
Mailing Address - Phone:928-774-3627
Mailing Address - Fax:927-774-1400
Practice Address - Street 1:2912 N WEST ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1974
Practice Address - Country:US
Practice Address - Phone:928-774-3627
Practice Address - Fax:927-774-1400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ151453Medicare PIN
AZZ71575Medicare PIN