Provider Demographics
NPI:1487616157
Name:PINAL MOUNTAIN INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:PINAL MOUNTAIN INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-402-0096
Mailing Address - Street 1:PO BOX 2260
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85532-2260
Mailing Address - Country:US
Mailing Address - Phone:928-402-0096
Mailing Address - Fax:928-402-0098
Practice Address - Street 1:5884 S HOSPITAL DRIVE
Practice Address - Street 2:SUITE #1
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-402-0096
Practice Address - Fax:928-402-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD14119AMedicare ID - Type Unspecified
C99850Medicare UPIN