=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346800646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAINSIDE MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 05/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4139 W BELL RD STE 8&9
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85053-2753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-319-7780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9365
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-0139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-687-7190
-----------------------------------------------------
Fax | 480-687-7292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | LIBAN OSMAN
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 480-687-7190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------