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: 06/19/2026
Certification Date: 06/19/2026
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: 480-856-8252
  • Fax: 470-268-9921
Mailing address:
  • Phone: 480-856-8252
  • Fax: 470-268-9921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAE H. KIM
Title or Position: CEO
Credential: MD
Phone: 480-856-8252