Provider Demographics
NPI:1992929004
Name:GILA VALLEY MEDICAL GROUP LLC
Entity type:Organization
Organization Name:GILA VALLEY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROOKSHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-344-6263
Mailing Address - Street 1:1951 WEST 25TH STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364
Mailing Address - Country:US
Mailing Address - Phone:928-344-6263
Mailing Address - Fax:
Practice Address - Street 1:1951 WEST 25TH STREET
Practice Address - Street 2:SUITE D
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364
Practice Address - Country:US
Practice Address - Phone:928-344-6263
Practice Address - Fax:928-785-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20396207Q00000X
AZ2125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
076275001OtherAACCS
076275001OtherAACCS
ZMD20396Medicare ID - Type Unspecified