Basic Information
Provider Information | |||||||||
NPI: | 1467092130 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIAN GROUP OF ARIZONA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STEWARD ORTHOPEDIC AND SPORTS MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 N PEARL STREET | ||||||||
Address2: | SUITE 2400 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752012470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4693418800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1492 S MILL AVE | ||||||||
Address2: | SUITE 113 | ||||||||
City: | TEMPE | ||||||||
State: | AZ | ||||||||
PostalCode: | 852815660 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6025533113 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2020 | ||||||||
LastUpdateDate: | 04/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DINSDALE | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6027977070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.