Provider Demographics
NPI:1750344347
Name:NORTH VALLEY FAMILY MEDICINE PC
Entity type:Organization
Organization Name:NORTH VALLEY FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-322-4991
Mailing Address - Street 1:6320 W UNION HILLS DR STE 2800B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1380
Mailing Address - Country:US
Mailing Address - Phone:623-322-4991
Mailing Address - Fax:623-322-9568
Practice Address - Street 1:6320 W UNION HILLS DR STE 2800B
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1380
Practice Address - Country:US
Practice Address - Phone:623-322-4991
Practice Address - Fax:623-322-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ07-646940-ROtherSTATE LICENSE
AZ=========85308A001OtherCHAMPUS
AZDA2344Medicare PIN
AZDA2344Medicare UPIN
AZ=========85308A001OtherCHAMPUS