Provider Demographics
NPI:1649256777
Name:COUNTRY CLUB MEDICAL GROUP P C
Entity type:Organization
Organization Name:COUNTRY CLUB MEDICAL GROUP P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SILVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-969-1446
Mailing Address - Street 1:1950 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6008
Mailing Address - Country:US
Mailing Address - Phone:480-969-1446
Mailing Address - Fax:480-969-9105
Practice Address - Street 1:1950 S COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6008
Practice Address - Country:US
Practice Address - Phone:480-969-1446
Practice Address - Fax:480-969-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCI5985Medicare ID - Type UnspecifiedRR MEDICARE GRP #
AZZ25218Medicare PIN