Provider Demographics
NPI:1144535626
Name:PONDEROSA FAMILY CARE, LLC
Entity type:Organization
Organization Name:PONDEROSA FAMILY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MICHELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-468-8603
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-2901
Mailing Address - Country:US
Mailing Address - Phone:928-468-9280
Mailing Address - Fax:
Practice Address - Street 1:806 S PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5541
Practice Address - Country:US
Practice Address - Phone:928-468-8603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29337208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ703422Medicaid
AZ703422Medicaid
AZZ74003Medicare PIN