Provider Demographics
NPI:1528256419
Name:MEDICORP, INC.
Entity type:Organization
Organization Name:MEDICORP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAKEEL
Authorized Official - Middle Name:AZIZ
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-768-1011
Mailing Address - Street 1:5225 S HIGHWAY 95
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9111
Mailing Address - Country:US
Mailing Address - Phone:928-768-1011
Mailing Address - Fax:928-768-1075
Practice Address - Street 1:5225 S HIGHWAY 95
Practice Address - Street 2:SUITE 5
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9111
Practice Address - Country:US
Practice Address - Phone:928-768-1011
Practice Address - Fax:928-768-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37896207QB0002X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ121688Medicare PIN