MEDICARE: NORTHERN APACHE COUNTY SPECIAL HEALTH CARE DISTRICT

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	OTC2967	AZ

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679757819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN APACHE COUNTY SPECIAL HEALTH CARE DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 370
Second Line	:
City	:	SAINT MICHAELS
State	:	AZ
Zip	:	86511-0370
Country	:	US
Telephone Number	:	928-810-3814
Fax Number	:	928-810-3811

Provider Business Practice Location Address
First Line	:	359 WEST HIGHWAY 264
Second Line	:	SUITE A
City	:	SAINT MICHAELS
State	:	AZ
Zip	:	86511
Country	:	US
Telephone Number	:	928-810-3800
Fax Number	:	928-810-3801

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	MRS. DAWN MARTINEZ
Credential	:
Telephone Number	:	928-810-3814

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	12/24/2007

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