MEDICARE: AJITH PURUSH MD PLC

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	253Z00000X	In Home Supportive Care Agency
2	261QM1300X	Multi-Specialty Clinic/Center
3	207R00000X	Internal Medicine Physician	33680	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00217872	OTHER	AZ	RR MEDICARE

General Provider Information

NPI Number	:	1487967519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AJITH PURUSH MD PLC

Provider Business Mailing Address
First Line	:	722 N MONTEZUMA ST
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-2002
Country	:	US
Telephone Number	:	928-237-9000
Fax Number	:	928-237-9011

Provider Business Practice Location Address
First Line	:	722 N MONTEZUMA ST
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-2002
Country	:	US
Telephone Number	:	928-237-9000
Fax Number	:	928-237-9011

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. AJITH PURUSH
Credential	:	MD
Telephone Number	:	928-710-1533

Provider Enumeration Date	:	07/18/2010
Last Update Date	:	11/16/2020

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Directions to “AJITH PURUSH MD PLC ” Practice Location

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