Basic Information
| Provider Information | |||||||||
| NPI: | 1790974830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTT R HAMBLIN MD, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNTAIN AVENUE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1610 | ||||||||
| Address2: | |||||||||
| City: | SPRINGERVILLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859381610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283335333 | ||||||||
| FaxNumber: | 9283335100 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EAGAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859259813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283335333 | ||||||||
| FaxNumber: | 9283335100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2007 | ||||||||
| LastUpdateDate: | 08/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | LESUEUR | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9283335333 | ||||||||
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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 | 207R00000X | 23187 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.