Provider Demographics
NPI:1639344591
Name:FAMILY PRACTICE OUTREACH, INC
Entity type:Organization
Organization Name:FAMILY PRACTICE OUTREACH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OF OPS
Authorized Official - Prefix:
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:COSENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-631-9585
Mailing Address - Street 1:7739 E BROADWAY BLVD # 360
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7739 E BROADWAY BLVD # 360
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3941
Practice Address - Country:US
Practice Address - Phone:520-631-9585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
68993Medicare PIN