Provider Demographics
NPI:1932449238
Name:BLACK MESA MEDICAL LLC
Entity type:Organization
Organization Name:BLACK MESA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:AINBINDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-677-2712
Mailing Address - Street 1:PO BOX 15070
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85267-5070
Mailing Address - Country:US
Mailing Address - Phone:480-421-9700
Mailing Address - Fax:480-421-9899
Practice Address - Street 1:20701 N SCOTTSDALE RD
Practice Address - Street 2:#107240
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6413
Practice Address - Country:US
Practice Address - Phone:602-677-2712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ337742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty