Basic Information
| Provider Information | |||||||||
| NPI: | 1215974951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARONDELET MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N. FORBES BLVD. | ||||||||
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| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208727536 | ||||||||
| FaxNumber: | 5208727929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1209 W. TARGET RANGE RD. | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202874747 | ||||||||
| FaxNumber: | 5202853135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | MOHESKY | ||||||||
| AuthorizedOfficialFirstName: | DEB | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 5208727745 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.