NPIMap

Organization Active NPI

Ponderosa Family Care, LLC

  • Internal Medicine Physician
  • Payson, AZ
National Provider Identifier
1144535626
Registry record updated Dec 5, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
29337 Issued in AZ
Legal business name
PONDEROSA FAMILY CARE, LLC
Practice address
806 S Ponderosa St
Payson, AZ 85541-5541
Phone
(928) 468-8603
NPI assigned
Aug 9, 2010
Last updated
Dec 5, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 5, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Alan P MichelsNPI 1376512129
Title
Physician
Phone
(928) 468-8603

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X 29337 AZ Primary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X 29337 AZ

Addresses

Primary practice location

806 S Ponderosa St
Payson, AZ 85541-5541

Mailing address

PO Box 2901
Payson, AZ 85547-2901
Phone (928) 468-9280

Other identifiers 1

IdentifierTypeStateIssuer
703422MedicaidAZ

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20101208000388 AZ Part B Supplier - Clinic/Group Practice 1456548015 Receives reassigned benefits from 14 practitioners
1 other NPI on this enrollment
Practice locations: Payson, AZ
O20191025001189 AZ DME Supplier - Physician - Internal Medicine 1456548015 Practice locations: Payson, AZ

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

708 S Coeur D Alene Ln
Payson, AZ 85541
Phone (602) 239-6324

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/CEIBDA

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1281312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1417737600000",
    "number": "1144535626",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 2901",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855472901",
            "telephone_number": "928-468-9280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "806 S PONDEROSA ST",
            "city": "PAYSON",
            "state": "AZ",
            "postal_code": "855415541",
            "telephone_number": "928-468-8603"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PONDEROSA FAMILY CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-08-09",
        "last_updated": "2014-12-05",
        "status": "A",
        "authorized_official_last_name": "MICHELS",
        "authorized_official_first_name": "ALAN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "928-468-8603",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "AZ",
            "license": "29337",
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "AZ",
            "license": "29337",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "703422",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Payson, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 5, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.