Provider Demographics
NPI:1770549974
Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Entity type:Organization
Organization Name:MT GRAHAM REGIONAL MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-348-4099
Mailing Address - Street 1:1600 S. 20TH AVE
Mailing Address - Street 2:BLDG. E
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546
Mailing Address - Country:US
Mailing Address - Phone:928-348-4063
Mailing Address - Fax:928-348-3868
Practice Address - Street 1:1600 S. 20TH AVE
Practice Address - Street 2:BLDG. E
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546
Practice Address - Country:US
Practice Address - Phone:928-348-4063
Practice Address - Fax:928-348-3868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MT GRAHAM REGIONAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-25
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHSPC-43251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ317786Medicaid
AZ03D0886073OtherCLIA NUMBER
AZHSPC-43OtherADHS NUMBER
AZ031522Medicare Oscar/Certification