Healthcare Provider Details

I. General information

NPI: 1609740455
Provider Name (Legal Business Name): THE GROUP GASTRO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10238 E HAMPTON AVE STE 205
MESA AZ
85209-3318
US

IV. Provider business mailing address

10238 E HAMPTON AVE STE 205
MESA AZ
85209-3318
US

V. Phone/Fax

Practice location:
  • Phone: 480-701-7687
  • Fax: 470-222-2768
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAE H. KIM
Title or Position: CEO
Credential:
Phone: 480-701-7687