Basic Information
| Provider Information | |||||||||
| NPI: | 1124649637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEORIA PHYSICIAN GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 964 | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852990964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803664489 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13760 N 93RD AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808096589 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | FABER | ||||||||
| AuthorizedOfficialFirstName: | JEREMIAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4802583635 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.