MEDICARE: FPS MEDICAL CENTER LTD

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	261QP2300X	Primary Care Clinic/Center
2	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CF9336	OTHER	AZ	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1538338058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FPS MEDICAL CENTER LTD

Provider Business Mailing Address
First Line	:	297 LAKE HAVASU AVE S STE 204
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6526
Country	:	US
Telephone Number	:	928-453-1970
Fax Number	:	928-855-7229

Provider Business Practice Location Address
First Line	:	297 LAKE HAVASU AVE S STE 204
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6526
Country	:	US
Telephone Number	:	928-453-1970
Fax Number	:	928-855-7229

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	KATIE PATRICK
Credential	:
Telephone Number	:	928-453-1970

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	10/12/2023

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Directions to “FPS MEDICAL CENTER LTD ” Practice Location

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