Basic Information
| Provider Information | |||||||||
| NPI: | 1902189905 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GILA RIVER HEALTH CARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KOMATKE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17487 S. HEALTH CARE DR. | ||||||||
| Address2: | |||||||||
| City: | LAVEEN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853390038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205506000 | ||||||||
| FaxNumber: | 5205506027 | ||||||||
| Practice Location | |||||||||
| Address1: | 17487 S. HEALTH CARE DR. | ||||||||
| Address2: | |||||||||
| City: | LAVEEN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853390038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205506000 | ||||||||
| FaxNumber: | 5205506027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 05/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | GEMBERLING | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6025281470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | AZ | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | TEZ055 | 01 | AZ | MEDICARE GROUP PTAN | OTHER |