MEDICARE: MRS. DORTHEA JEANETTE FINICUM

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	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8A4763	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1063572154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DORTHEA JEANETTE FINICUM

Provider Business Mailing Address
First Line	:	PO BOX 98
Second Line	:
City	:	PAULDEN
State	:	AZ
Zip	:	86334-0098
Country	:	US
Telephone Number	:	928-636-0505
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 MONTE VISTA
Second Line	:
City	:	PAULDEN
State	:	AZ
Zip	:	96334
Country	:	US
Telephone Number	:	928-636-0505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	07/08/2007

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