Provider Demographics
NPI:1538740592
Name:PINETOP PRIMARY PALLIATIVE CARE PLLC
Entity type:Organization
Organization Name:PINETOP PRIMARY PALLIATIVE CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:928-367-1077
Mailing Address - Street 1:PO BOX 888
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-0888
Mailing Address - Country:US
Mailing Address - Phone:928-367-1077
Mailing Address - Fax:
Practice Address - Street 1:300 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7014
Practice Address - Country:US
Practice Address - Phone:928-367-1077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ300123Medicaid