Basic Information
| Provider Information | |||||||||
| NPI: | 1073970059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN MEDICAL MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1888 N COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203276367 | ||||||||
| FaxNumber: | 5203184492 | ||||||||
| Practice Location | |||||||||
| Address1: | 1888 N COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857163115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203276367 | ||||||||
| FaxNumber: | 5203184492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2016 | ||||||||
| LastUpdateDate: | 06/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | HUSTON | ||||||||
| AuthorizedOfficialFirstName: | ERIKA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | INITIAL MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5209067904 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0683 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.