MEDICARE: WEST FAMILY PRACTICE AND OBSTETRICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	27671	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z109137	OTHER	AZ	MEDICARE ID-PIN

General Provider Information

NPI Number	:	1003996224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST FAMILY PRACTICE AND OBSTETRICS

Provider Business Mailing Address
First Line	:	PO BOX 8400
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427-8400
Country	:	US
Telephone Number	:	928-788-9378
Fax Number	:	928-788-9381

Provider Business Practice Location Address
First Line	:	1510 E WAGON WHEEL LN
Second Line	:	SUITE 106
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6697
Country	:	US
Telephone Number	:	928-788-9378
Fax Number	:	928-788-9381

Authorized Official
Title or Position	:	OWNER
Name	:	GERALD C WEST
Credential	:	MD
Telephone Number	:	928-788-9378

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	02/02/2011

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Directions to “WEST FAMILY PRACTICE AND OBSTETRICS ” Practice Location

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