MEDICARE: SAG, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	208VP0014X	Interventional Pain Medicine Physician
2	261QP3300X	Pain Clinic/Center	AZ
3	261QP3300X	Pain Clinic/Center
4	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033359419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAG, LLC

Provider Business Mailing Address
First Line	:	4220 N 20TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-5124
Country	:	US
Telephone Number	:	602-889-9401
Fax Number	:	602-889-9404

Provider Business Practice Location Address
First Line	:	3306 W ROOSEVELT ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85009-3404
Country	:	US
Telephone Number	:	602-889-9401
Fax Number	:	602-269-7772

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	ROSE MATA-ESPINOZA
Credential	:
Telephone Number	:	602-687-8219

Provider Enumeration Date	:	02/25/2009
Last Update Date	:	07/21/2022

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Directions to “SAG, LLC ” Practice Location

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