Basic Information
| Provider Information | |||||||||
| NPI: | 1154453728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINETOP MEDICAL ASSOCIATES LTD | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUE RIDGE REGIONAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2690 | ||||||||
| Address2: | |||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859352690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283676688 | ||||||||
| FaxNumber: | 9283674916 | ||||||||
| Practice Location | |||||||||
| Address1: | 728 E WHITE MOUNTAIN BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859357027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283676688 | ||||||||
| FaxNumber: | 9383674916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 05/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | PAXMAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9283676688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2577 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.