Basic Information
| Provider Information | |||||||||
| NPI: | 1104354752 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBELT MEDICAL GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2850 NORTH COUNTRY CLUB ROAD | ||||||||
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| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857161910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203226274 | ||||||||
| FaxNumber: | 5206094496 | ||||||||
| Practice Location | |||||||||
| Address1: | 3988 E FORT LOWELL RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857121010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204885291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5203226274 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 274404 | 05 | AZ | MEDICAID | 7804700001 | 01 | DEMPOS | OTHER |