Provider Demographics
NPI:1205962792
Name:MEDCOM MEDICAL, LLC
Entity type:Organization
Organization Name:MEDCOM MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:ANDRADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-402-0952
Mailing Address - Street 1:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85539
Mailing Address - Country:US
Mailing Address - Phone:928-402-0952
Mailing Address - Fax:928-402-4774
Practice Address - Street 1:108 SOUTH BROAD ST.
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-425-6592
Practice Address - Fax:928-425-7566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1225107667OtherSHERIDA CARLSON PA NPI
AZ475592Medicaid
AZ1871545905OtherJEAN TURNEY-SHAW FPN NPI
AZ1275685521OtherAZ NPI OSCAR ERNEST ANDRA
AZZ71801Medicare PIN
AZG41048Medicare PIN
G41048Medicare UPIN
AZ475592Medicaid
AZG41048Medicare PIN