Provider Demographics
NPI:1699159111
Name:NORTHERN ARIZONA MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:NORTHERN ARIZONA MEDICAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEUBARTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-757-8440
Mailing Address - Street 1:3555 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3011
Mailing Address - Country:US
Mailing Address - Phone:928-757-8440
Mailing Address - Fax:928-757-5460
Practice Address - Street 1:3555 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3011
Practice Address - Country:US
Practice Address - Phone:928-757-8440
Practice Address - Fax:928-757-5460
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN ARIZONA MEDICAL GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-14
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QU0200X
AZ32218261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ357676Medicaid