Basic Information
| Provider Information | |||||||||
| NPI: | 1366796773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL GROUP OF ARIZONA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4616 N 51ST AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806868737 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 13430 N. BLACK CANYON HIGHWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850291310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2012 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | SUTTON | ||||||||
| AuthorizedOfficialFirstName: | REGINALD | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4806868737 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 29166 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.