Healthcare Provider Details

I. General information

NPI: 1447096417
Provider Name (Legal Business Name): AJMEDICUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1467 PALMA RD STE 4
BULLHEAD CITY AZ
86442-6785
US

IV. Provider business mailing address

1846 E INNOVATION PARK DR STE 100
ORO VALLEY AZ
85755-1963
US

V. Phone/Fax

Practice location:
  • Phone: 561-573-8521
  • Fax:
Mailing address:
  • Phone: 561-573-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL JOSEPH
Title or Position: PROVIDER, MANAGER
Credential: PA-C
Phone: 561-573-8521