MEDICARE: PIERPONT MEDICAL GROUP, LTD

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	14449	AZ

General Provider Information

NPI Number	:	1548389265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIERPONT MEDICAL GROUP, LTD

Provider Business Mailing Address
First Line	:	9221 E BASELINE RD
Second Line	:	SUITE A109, #289
City	:	MESA
State	:	AZ
Zip	:	85209-8310
Country	:	US
Telephone Number	:	480-830-1040
Fax Number	:	480-981-3130

Provider Business Practice Location Address
First Line	:	4852 E BASELINE RD
Second Line	:	SUITE #103
City	:	MESA
State	:	AZ
Zip	:	85206-4627
Country	:	US
Telephone Number	:	480-830-1040
Fax Number	:	480-981-3130

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. ROBIN LYNN NICE
Credential	:
Telephone Number	:	480-830-1040

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/22/2020

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