Basic Information
Provider Information | |||||||||
NPI: | 1396993978 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MT. GRAHAM REGIONAL MEDICAL CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MT. GRAHAM REGIONAL MEDICAL CENTER PROFEES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 S 20TH AVE | ||||||||
Address2: |   | ||||||||
City: | SAFFORD | ||||||||
State: | AZ | ||||||||
PostalCode: | 855464011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283484021 | ||||||||
FaxNumber: | 9283484018 | ||||||||
Practice Location | |||||||||
Address1: | 1600 S 20TH AVE | ||||||||
Address2: |   | ||||||||
City: | SAFFORD | ||||||||
State: | AZ | ||||||||
PostalCode: | 855464011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283484021 | ||||||||
FaxNumber: | 9283484018 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2008 | ||||||||
LastUpdateDate: | 07/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRYCE | ||||||||
AuthorizedOfficialFirstName: | DEWEY | ||||||||
AuthorizedOfficialMiddleName: | KEITH | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9283484099 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H0140 | AZ | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | ZM03006806 | 01 | AZ | MEDICARE ID | OTHER | 196396 | 05 | AZ |   | MEDICAID |