Basic Information
| Provider Information | |||||||||
| NPI: | 1306009519 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN HEART MEDICAL PRACTICE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 S THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860018759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282266400 | ||||||||
| FaxNumber: | 9282266411 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 S THOMPSON ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860018759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282266400 | ||||||||
| FaxNumber: | 9282266411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | DUVAL | ||||||||
| AuthorizedOfficialFirstName: | SUZANNE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 90282266400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 30420 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.