Basic Information
| Provider Information | |||||||||
| NPI: | 1740232768 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OB&G PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OB&G PROFESSIONAL LTD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36680 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850676680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022341803 | ||||||||
| FaxNumber: | 6022343748 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W CLARENDON AVE | ||||||||
| Address2: | SUITE 142 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022341803 | ||||||||
| FaxNumber: | 6022343748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | KUSH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6022341803 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 173807 | 05 | AZ | MEDICAID |