Basic Information
| Provider Information | |||||||||
| NPI: | 1518137520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN GROUP OF ARIZONA INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEWARD MEDICAL GROUP OF ARIZONA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 281201 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662437104 | ||||||||
| FaxNumber: | 3144329683 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 E WASHINGTON ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850342004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025074500 | ||||||||
| FaxNumber: | 6026888311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOCH | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6175627070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 323426 | 05 | AZ | MEDICAID |