Provider Demographics
NPI:1902162639
Name:MOUNTAIN VISTA MEDICAL CENTER LP
Entity Type:Organization
Organization Name:MOUNTAIN VISTA MEDICAL CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOSPITAL CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-358-6100
Mailing Address - Street 1:1301 S CRISMON RD
Mailing Address - Street 2:ATTN: BILLING
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3767
Mailing Address - Country:US
Mailing Address - Phone:480-358-6100
Mailing Address - Fax:480-358-6168
Practice Address - Street 1:1301 S CRISMON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3767
Practice Address - Country:US
Practice Address - Phone:480-358-6100
Practice Address - Fax:480-358-6168
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN VISTA MEDICAL CENTER LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-06
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03S121Medicare Oscar/Certification