MEDICARE: MOUNTAINSIDE MEDICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1346800646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINSIDE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 9365
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-0139
Country	:	US
Telephone Number	:	480-687-7190
Fax Number	:	480-687-7292

Provider Business Practice Location Address
First Line	:	4139 W BELL RD STE 8&9
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85053-2753
Country	:	US
Telephone Number	:	507-319-7780
Fax Number	:

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	LIBAN OSMAN
Credential	:	FNP
Telephone Number	:	480-687-7190

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	05/07/2020

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