Provider Demographics
NPI:1720207087
Name:RED MOUNTAIN FAMILY MEDICINE
Entity Type:Organization
Organization Name:RED MOUNTAIN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-854-7123
Mailing Address - Street 1:1635 N GREENFIELD RD
Mailing Address - Street 2:#134
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205
Mailing Address - Country:US
Mailing Address - Phone:480-854-7123
Mailing Address - Fax:480-854-7627
Practice Address - Street 1:1635 N GREENFIELD RD
Practice Address - Street 2:#134
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205
Practice Address - Country:US
Practice Address - Phone:480-854-7123
Practice Address - Fax:480-854-7627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWDBVZ01Medicare PIN
AZZ103193Medicare PIN