Basic Information
| Provider Information | |||||||||
| NPI: | 1568870426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILMOT PRIMARY CARE GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 603 N WILMOT RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857112701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207901556 | ||||||||
| FaxNumber: | 5206209719 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 N WILMOT RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857112701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207901556 | ||||||||
| FaxNumber: | 5206209719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2014 | ||||||||
| LastUpdateDate: | 12/15/2014 | ||||||||
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| AuthorizedOfficialLastName: | ALSBIEI | ||||||||
| AuthorizedOfficialFirstName: | TALAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 5207901556 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.