Provider Demographics
NPI:1104167154
Name:PIERPONT FAMILY MEDICINE
Entity type:Organization
Organization Name:PIERPONT FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:FRYE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-284-8463
Mailing Address - Street 1:4838 E BASELINE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4671
Mailing Address - Country:US
Mailing Address - Phone:480-926-8000
Mailing Address - Fax:480-926-3445
Practice Address - Street 1:4838 E BASELINE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4671
Practice Address - Country:US
Practice Address - Phone:480-926-8000
Practice Address - Fax:480-926-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty