MEDICARE: WILLOW VALLEY MEDICAL CENTER PC

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	207Q00000X	Family Medicine Physician	13491	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DI935A	OTHER	CA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	AZ0325100	OTHER	AZ	AZ BCBS

General Provider Information

NPI Number	:	1134111834
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW VALLEY MEDICAL CENTER PC

Provider Business Mailing Address
First Line	:	8700 HIGHWAY 95
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86440-8519
Country	:	US
Telephone Number	:	760-217-2464
Fax Number	:	928-453-9207

Provider Business Practice Location Address
First Line	:	8700 HIGHWAY 95
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86440-8519
Country	:	US
Telephone Number	:	760-217-2464
Fax Number	:	928-453-9207

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DONOVAN J ANDERSON
Credential	:	MD
Telephone Number	:	760-217-2464

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	02/08/2018

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Directions to “WILLOW VALLEY MEDICAL CENTER PC ” Practice Location

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