Provider Demographics
NPI:1063603470
Name:MESA CLINIC OF PHYSICIANS AND SURGEONS, PLLC.
Entity type:Organization
Organization Name:MESA CLINIC OF PHYSICIANS AND SURGEONS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-733-4401
Mailing Address - Street 1:606 N COUNTRY CLUB DR
Mailing Address - Street 2:#1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201
Mailing Address - Country:US
Mailing Address - Phone:480-733-4432
Mailing Address - Fax:480-733-4447
Practice Address - Street 1:606 N COUNTRY CLUB DR
Practice Address - Street 2:#1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-969-3511
Practice Address - Fax:480-969-0976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZWCFCXMedicare ID - Type Unspecified