Basic Information
| Provider Information | |||||||||
| NPI: | 1932449238 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK MESA MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15070 | ||||||||
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| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852675070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804219700 | ||||||||
| FaxNumber: | 4804219899 | ||||||||
| Practice Location | |||||||||
| Address1: | 20701 N SCOTTSDALE RD | ||||||||
| Address2: | #107240 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852556413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026772712 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2013 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | AINBINDER | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6026772712 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 33774 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.