Provider Demographics
NPI:1457603771
Name:FOUNTAIN HILLS MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:FOUNTAIN HILLS MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOTTFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-837-4300
Mailing Address - Street 1:16605 E PALISADES BLVD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-3716
Mailing Address - Country:US
Mailing Address - Phone:480-837-4300
Mailing Address - Fax:480-837-8302
Practice Address - Street 1:16605 E PALISADES BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3716
Practice Address - Country:US
Practice Address - Phone:480-837-4300
Practice Address - Fax:480-837-8302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-10
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7914261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZMD7914Medicare UPIN