MEDICARE: PHYSICIAN GROUP OF ARIZONA INC

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	174400000X	Specialist

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	:	1518137520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN GROUP OF ARIZONA INC

Provider Business Mailing Address
First Line	:	PO BOX 281201
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-1201
Country	:	US
Telephone Number	:	866-243-7104
Fax Number	:	314-432-9683

Provider Business Practice Location Address
First Line	:	4801 E WASHINGTON ST
Second Line	:	SUITE 200
City	:	PHOENIX
State	:	AZ
Zip	:	85034-2004
Country	:	US
Telephone Number	:	602-507-4500
Fax Number	:	602-688-8311

Authorized Official
Title or Position	:	CFO
Name	:	ASHLEY KOCH
Credential	:
Telephone Number	:	617-562-7070

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/06/2020

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