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General NPI Number Information
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NPI Number | 1689813834
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Entity Type | Organization
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Legal Business Name | GERALD J TAITAGUE MD PC
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Dates
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Enumeration Date | 02/11/2009
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Last Update Date | 02/11/2009
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Provider Practice Location Address
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Address Line | 117 W ROUTE 66 SUITE 190
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City | WILLIAMS
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State | AZ
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Zip | 86046-2567
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Country | US
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Telephone | 928-635-1044
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Fax | 928-635-1042
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Provider Business Mailing Address
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Address Line | 117 W ROUTE 66 SUITE 190
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City | WILLIAMS
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State | AZ
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Zip | 86046-2567
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Country | US
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Telephone | 928-635-1044
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Fax | 928-635-1042
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Authorized Official
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Title or Position | PRESIDENT/PHYSICIAN
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Name | GERALD J TAITAGUE
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Credential | M.D.
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Telephone | 928-635-1044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 26182
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License Number State | AZ
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