Basic Information
| Provider Information | |||||||||
| NPI: | 1649733981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PV MOUNTAIN MEDICAL PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4531 N 16TH ST STE 114 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850165344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808393313 | ||||||||
| FaxNumber: | 6022960404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1728 W GLENDALE AVE STE 204 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850218863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235224935 | ||||||||
| FaxNumber: | 6235224937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2019 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | QURESHI | ||||||||
| AuthorizedOfficialFirstName: | JUNAID | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6023779598 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 506223 | 05 | AZ | MEDICAID |