Healthcare Provider Details

I. General information

NPI: 1992929004
Provider Name (Legal Business Name): GILA VALLEY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 WEST 25TH STREET SUITE D
YUMA AZ
85364
US

IV. Provider business mailing address

1951 WEST 25TH STREET SUITE D
YUMA AZ
85364
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-6263
  • Fax: 928-785-9572
Mailing address:
  • Phone: 928-344-6263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2125
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20396
License Number StateAZ

VIII. Authorized Official

Name: RONALD D BROOKSHER
Title or Position: OWNER
Credential: MD
Phone: 928-344-6263