Basic Information
| Provider Information | |||||||||
| NPI: | 1801189519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRP FACILITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36395 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850139998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028899880 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3330 N 2ND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028899880 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2011 | ||||||||
| LastUpdateDate: | 05/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | SANJAY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6028899880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SRP FACILITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.