Basic Information
| Provider Information | |||||||||
| NPI: | 1780155077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PB MEDICAL GROUP OF ARIZONA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7444 LONG AVE | ||||||||
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| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600773214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473294100 | ||||||||
| FaxNumber: | 8473294900 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 N 91ST AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808402588 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2018 | ||||||||
| LastUpdateDate: | 12/11/2018 | ||||||||
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| AuthorizedOfficialLastName: | KUCHINSKAS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PAYER RELATIONS & OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5623039741 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.