MEDICARE: SOUTHEAST VALLEY OBSTETRICS & GYNECOLOGY PLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	2605	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75322	OTHER	AZ	MEDICARE

General Provider Information

NPI Number	:	1427154442
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST VALLEY OBSTETRICS & GYNECOLOGY PLC

Provider Business Mailing Address
First Line	:	4566 E INVERNESS AVE
Second Line	:	SUITE 202
City	:	MESA
State	:	AZ
Zip	:	85206-4633
Country	:	US
Telephone Number	:	480-464-2101
Fax Number	:	480-854-4913

Provider Business Practice Location Address
First Line	:	4566 E INVERNESS AVE
Second Line	:	SUITE 202
City	:	MESA
State	:	AZ
Zip	:	85206-4633
Country	:	US
Telephone Number	:	480-464-2101
Fax Number	:	480-854-4913

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SIDNEY E SEMRAD
Credential	:	D.O.
Telephone Number	:	480-464-2101

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	02/03/2015

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