Healthcare Provider Details

I. General information

NPI: 1881680122
Provider Name (Legal Business Name): ARIZONA INSTITUTE OF MEDICINE AND SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 STOCKTON HILL ROAD
KINGMAN AZ
86409
US

IV. Provider business mailing address

3636 STOCKTON HILL ROAD
KINGMAN AZ
86409
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-3680
  • Fax: 928-757-3614
Mailing address:
  • Phone: 928-757-3680
  • Fax: 928-757-3614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberOTC660
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOTC660
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AZAM S. KHAN
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 928-757-3636