Provider Demographics
NPI:1215974951
Name:CARONDELET MEDICAL GROUP, INC
Entity type:Organization
Organization Name:CARONDELET MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DEB
Authorized Official - Middle Name:S
Authorized Official - Last Name:MOHESKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-872-7745
Mailing Address - Street 1:2202 N. FORBES BLVD.
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745
Mailing Address - Country:US
Mailing Address - Phone:520-872-7536
Mailing Address - Fax:520-872-7929
Practice Address - Street 1:1209 W. TARGET RANGE RD.
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621
Practice Address - Country:US
Practice Address - Phone:520-287-4747
Practice Address - Fax:520-285-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
28678Medicare ID - Type Unspecified